Dr. Gamini Goonetilleke,
& Dr Ruwan M Jayatunge
The prolonged
armed conflict in Sri Lanka, which lasted three decades, has left a devastating
legacy of landmines that have caused severe physical injuries among combatants,
Tamil Tigers, aka LTTE guerrillas, and civilians. The occurrence of landmine
injuries during the Sri Lankan conflict was alarmingly high. As the conflict
escalated, the use of landmines became a common tactic, leading to widespread
contamination of large areas of land. This caused numerous casualties, with
many individuals suffering from serious injuries that often resulted in
permanent disabilities.
Sri Lankan soldiers
engaged in the military conflict frequently fell victim to landmines
strategically placed by the LTTE (Liberation Tigers of Tamil Eelam) guerrillas,
resulting in numerous fatalities and leaving many survivors with life-altering
disabilities. The Sri Lankan military employed landmines as a strategic measure
to secure the boundaries of their encampments, creating a formidable barrier
against potential incursions. These explosive devices became a lethal threat to
members of the LTTE. In the height of the battle, both parties extensively
employed both anti-personnel and anti-vehicle mines as part of their defensive
strategies during the prolonged conflict in the region
The impact of
landmines extended beyond the battlefield, as a large number of civilians
encountered these hidden dangers while pursuing agricultural activities in
post-war landscapes still littered with explosives. The repercussions for those
injured by landmines are profound, encompassing not only physical ailments but
also deep psychological scars. Many victims endure chronic pain and mobility
issues, compounded by mental health challenges stemming from their traumatic
experiences. Consequently, these individuals require extensive long-term
medical care and rehabilitation to address both their physical and
psychological needs.
Types of Landmines used in the Sri Lankan Conflict
According to
Mannion and Chaloner (2006), antipersonnel landmines can be categorized into
two primary types. The first type, known as blast mines, is typically concealed
underground and is activated by the pressure exerted by a person's foot. The
injuries resulting from these mines stem not only from the explosive force but
also from the intense thermal effects produced during detonation. The second
type is fragmentation mines that are typically positioned above ground and are
triggered by trip wires or various sensors. Their explosive charge is engineered
to disperse hundreds of small, lethal fragments across a designated target
area.
The Sri Lankan
Security Forces employed a variety of explosive devices during their
operations, including Claymore mines, anti-vehicle mines, and anti-personnel
mines. Among the anti-personnel mines utilized were the Chinese Type 72, the
Italian VS50, and the Pakistani PV4, each designed to inflict significant harm
on enemy personnel.
The Liberation
Tigers of Tamil Eelam (LTTE) employed a variety of explosive devices in their
operations, including Claymore mines, which are directional anti-personnel
explosives designed to inflict maximum damage on targets within a specific
range. Additionally, they utilized anti-vehicle mines, which are specifically
engineered to disable or destroy vehicles, thereby hindering enemy mobility and
logistics. The LTTE also made use of anti-personnel Jony mines, known for their
capacity to target individuals, causing injury or death to soldiers and
civilians alike.
Pattern of Injuries following Landmine Explosions
Landmine blasts
cause severe somatic injuries from blasts and fragments. The legs are
especially at risk due to their closeness to the ground, experiencing
significant soft-tissue damage and other limb injuries. Bone fractures are a frequent occurrence, and
when they happen, debris can often get lodged in the wound. This contamination
can result in serious infections and additional damage to surrounding tissue.
Victims frequently
experience "blast lung," a condition marked by frothy secretions,
hypoxia, and significant respiratory distress, necessitating mechanical
ventilation for survival. In cases of penetrating abdominal injuries, emergency
laparotomy is essential, while chest injuries typically require the insertion
of chest drains, with thoracotomy being a rare intervention.
Additionally,
those exposed to detonations at close range commonly suffer from hearing loss
and ocular trauma. Secondary blast injuries arise when fragments from the
explosive device embed themselves in the body or penetrate various tissues. At
close range, these fragments act like high-velocity projectiles, creating
cavitation effects and leading to contaminated wounds.
The shock wave
generated by these fragments can inflict damage on organs and tissues located
far from the initial point of penetration. Such injuries demand careful
surgical debridement, delayed wound closure, and staged operations to mitigate
the risk of infection and facilitate gradual healing. Furthermore, the blast wind
effect, resulting from the intense shockwave, can propel victims into nearby
objects, resulting in multiple fractures and blunt trauma to the head, chest,
and abdomen. Claymore mines, known for their wide dispersal of high-velocity
fragments, often cause injuries to the face, chest, and limbs, which typically
require numerous reconstructive surgeries and extended hospital stays for
recovery.
Anti-personnel
mines are specifically engineered to inflict injury rather than to cause death,
with the primary objective of incapacitating individuals. The most prevalent
type of injury occurs when a person inadvertently steps on one of these
devices, leading to a staggering 80% of cases resulting in below-knee
amputations.
In addition to
this, many victims experience a range of other traumatic injuries, including
severe lacerations and shrapnel wounds from explosive fragments. Survivors
often endure debilitating eye injuries, loss of upper limbs, and, in some
tragic instances, life-threatening injuries to vital areas such as the chest
and abdomen. The long-term consequences of these injuries extend beyond
physical impairments, profoundly affecting the psychological well-being and
quality of life of those affected.
A State of Shock Following a Landmine Injury
A A landmine
injury can trigger a state of shock that poses an immediate and
life-threatening risk to the individual. This shock is characterized by
significant blood loss or extensive tissue damage, resulting in critical
symptoms such as hypotension, tachycardia, cold and clammy skin, and changes in
mental status. The unique nature of landmine explosions contributes to this
condition, as victims may suffer from traumatic amputations, severe lacerations
caused by flying debris, and various internal injuries. Effective management of
this shock is crucial and involves several key interventions: controlling any
active bleeding, ensuring the airway remains clear, and maintaining adequate
circulation. Prompt and appropriate medical care is essential to mitigate the
risk of catastrophic organ failure, which can occur if the shock is not
addressed swiftly and effectively.
Emergency Care in Field Settings
In
resource-limited settings, the management of injuries presents significant
challenges, particularly in field conditions and smaller hospitals. Casualties
often arrive unexpectedly, frequently without having received any initial first
aid at the scene of the incident. The transportation of these individuals is
fraught with difficulties, as the process is typically slow and hazardous;
field ambulances were seldom utilized, leading to the use of army jeeps or
trucks that must navigate treacherous terrain. While helicopters are
occasionally deployed for urgent cases, their availability is limited. Once at
the hospital, the situation does not improve, as facilities are often equipped
with minimal surgical capabilities and a shortage of medical personnel. Compounding
these issues are inadequate blood supplies and insufficient anesthetic support,
which further complicate the treatment of injured patients and highlight the
critical need for improved resources and infrastructure in such environments.
In the event of
mine-related injuries, it is crucial to take immediate and decisive actions to
mitigate the consequences of such traumatic incidents. The priority is to
control any severe bleeding, which can be life-threatening if not addressed
promptly. This involves applying direct pressure to the wound and, if
necessary, utilizing tourniquets to stem the flow of blood. Following this, it
is essential to protect the wound from further contamination and injury, which
can exacerbate the damage and increase the risk of infection. Additionally,
treating for shock is vital, as victims may experience a rapid decline in their
physiological state due to blood loss and trauma. This can include keeping the
individual calm, lying down, and elevating their legs if there are no contraindications.
Finally, initiating a swift evacuation to a medical facility is imperative, as
mine injuries frequently lead to traumatic amputations and extensive tissue
damage that require specialized medical intervention. The combination of these
actions can significantly improve the chances of survival and recovery for
those affected by such devastating injuries.
Definitive Care and the Multidisciplinary Approach
In cases where
patients required advanced reconstructive surgeries, they were often
transferred to larger tertiary care facilities, frequently accompanied by
military escorts to guarantee their safety during transit. At these specialized
hospitals, a multidisciplinary approach was employed to deliver holistic care
tailored to the complex needs of these individuals. Orthopaedic surgeons took
charge of stabilizing fractures through precise fixation techniques, while
plastic surgeons focused on intricate soft tissue reconstruction to ensure
optimal healing and aesthetic outcomes. Concurrently, physiotherapists
initiated early mobilization strategies to mitigate the risks associated with
prolonged immobility, thereby enhancing recovery prospects. Additionally, prosthetic
technicians played a crucial role by facilitating the timely fitting of
artificial limbs, ensuring that patients could regain mobility as swiftly as
possible. Recognizing the significant psychological toll of such traumatic
injuries, psychiatrists and counselors were also integral to the care team,
providing essential support to help patients navigate the emotional challenges
they faced during their recovery journey.
The
Psychological Impact
The psychological
consequences of landmine injuries are profound and multifaceted, often
manifesting as elevated levels of anxiety, depression, and Post-Traumatic
Stress Disorder (PTSD). Survivors frequently face social stigmatization, which
can exacerbate feelings of isolation and despair, alongside challenges such as
unemployment and a diminished sense of independence. These factors contribute
to a cycle of emotional distress that significantly undermines their overall
quality of life. The journey toward psychological recovery is influenced by
several critical elements, including the individual's inherent resilience, the
presence of a robust support network, and access to comprehensive medical and
psychological care. Additionally, the attitudes of society play a pivotal role;
supportive and understanding communities can foster healing and reintegration,
while negative perceptions can hinder recovery efforts and perpetuate
suffering.
Psychological Care for the Victims
Psychological care
for individuals affected by landmines encompasses a diverse array of therapeutic
techniques, ranging from conventional methods such as psychotherapy and family
counseling to more contemporary interventions like creative arts therapy,
virtual reality therapy, and peer support networks. These therapeutic
modalities are designed to tackle a variety of issues, including the
psychological aftermath of trauma, symptoms of depression and anxiety, as well
as the physical pain that often accompanies such injuries. Additionally, they
address the complex challenges of social reintegration, which may include
difficulties in finding employment and the disruption of established social
roles. The effectiveness of these treatments is significantly enhanced by
robust support systems, particularly community-based initiatives that focus on
educating families and training local social workers. Such programs are
essential for ensuring that recovery efforts are culturally sensitive and
sustainable, ultimately fostering a more comprehensive approach to healing for
landmine survivors.
Rehabilitation
Rehabilitation
encompasses much more than merely addressing physical injuries and fitting
prosthetics; it involves a comprehensive approach to recovery that includes
various facets of physical and psychological healing. The process of physical
recovery entails not only the fitting of prosthetic limbs but also essential
training in their use, gait rehabilitation, and targeted strengthening
exercises to restore mobility and function. Additionally, vocational training
plays a crucial role in helping survivors regain their economic independence,
allowing them to reintegrate into the workforce and reclaim their sense of
purpose. However, the psychological impact of such traumatic experiences can be
equally debilitating, with many survivors grappling with post-traumatic stress
disorder (PTSD), which manifests through symptoms such as flashbacks,
nightmares, anxiety, and depression. This psychological burden is often
exacerbated for some of the amputees, who may face social stigma that
intensifies their feelings of isolation and negatively affects their overall
quality of life. Therefore, achieving true recovery necessitates a holistic
approach that integrates physical rehabilitation with mental health support,
family counseling, and community reintegration programs, ensuring that
survivors receive the comprehensive care they need to heal both body and mind.
The Social Cost of Land Mine Injuries
The social
repercussions of landmines in Sri Lanka are profound and far-reaching,
resulting in significant civilian casualties and injuries that often lead to
permanent disabilities and enduring psychological distress. These hidden
explosives not only claim lives but also dismantle the economic infrastructure
of affected areas, rendering agricultural land unusable and obstructing trade
routes essential for local commerce. Furthermore, the presence of landmines
complicates the resettlement process for refugees, as individuals and families
are hesitant to return to their homes when the threat of detonation looms. This
pervasive danger fosters an atmosphere of fear that stifles community recovery
and development, creating a cycle of hardship that can last for generations.
The long-term effects of landmines extend beyond immediate physical harm,
embedding a sense of insecurity that hinders social cohesion and economic
revitalization, ultimately stalling progress for entire communities.
The Impact of Landmines on Children
In 2010, UNICEF
reported that children made up 20% of mine victims in Sri Lanka. Children in
Sri Lanka face a significant risk of becoming victims of landmines, primarily
due to the deceptive nature of these explosives and the hazardous activities
they often engage in, such as land burning and scavenging.
The impact of
landmines on children in Sri Lanka is profound and multifaceted, resulting in
both direct and indirect consequences. Directly, these explosive remnants of
war can cause severe injuries or fatalities among young individuals, who are
often unaware of the dangers posed by such devices. Indirectly, the presence of
landmines disrupts the daily lives of children, leading to significant barriers
in accessing education, agricultural land, and vital infrastructure necessary
for their development and well-being.
Children, driven
by their natural curiosity, are particularly susceptible to the risks
associated with landmines and unexploded ordnance (UXO), which they may
misidentify as toys or intriguing objects. This tragic combination of factors
not only endangers their physical safety but also hinders their opportunities
for growth and learning, perpetuating a cycle of trauma and deprivation in
communities affected by conflict.
The Mine Ban Treaty and Sri Lanka’s Path to a
Mine-Free Nation
Injuries and fatalities caused by anti-personnel landmines
have become a global epidemic (McIvor Joss 1997), and the presence of mines
causes a serious environmental, social, and economic burden (Jeffrey, 1996). Therefore, the Mine Ban Treaty
represents a significant international effort aimed at eradicating landmines
and ensuring the safety of communities affected by these dangerous remnants of
conflict.
In light of the
extensive humanitarian crises triggered by landmines over several decades,
organizations such as the International Campaign to Ban Landmines (ICBL),
established in 1992, have dedicated themselves to highlighting the profound suffering
inflicted by these weapons in various nations, including Cambodia, Laos,
Afghanistan, Bosnia, and Angola. Their advocacy efforts received significant
support from prominent entities like the Red Cross and the United Nations,
which collectively urged for a comprehensive ban on landmines. This relentless
campaign ultimately led to the establishment of the Mine Ban Treaty, which was
signed on December 3, 1997, and came into force in 1999, effectively
prohibiting the production, use, stockpiling, and transfer of anti-personnel
landmines.
Sri Lanka
officially joined the Mine Ban Treaty in December 2017, with its provisions
taking effect on June 1, 2018. As stipulated in Article V of the Treaty, Sri
Lanka is committed to declaring itself a mine-free nation by 2028. The country
initiated its mine action program in 2002, particularly focusing on the
war-affected Northern and Eastern regions, by implementing the internationally
recognized five pillars of mine action under the coordination of the Sri Lanka
Mine Action Program. However, the escalation of conflict during that period
necessitated the suspension of these vital efforts. Mine action was resumed in
2010 after the war ended in May 2009 and is progressing smoothly with the
support of various national and international agencies, together with overseas
funding, to achieve its target of making Sri Lanka a mine-free nation by 2028.
Dr. Gamini Goonetilleke, FRCS
is a senior consultant surgeon from Sri Lanka with over four decades of
distinguished service. His career spans a wide range of hospitals across the
country, including extended service in conflict-affected zones during Sri
Lanka’s civil war, where he gained extensive experience in managing complex
battle-related injuries.
Dr.
Ruwan M. Jayatunge, M.D., PhD, is a medical doctor and a clinical psychologist,
and also a member of the American Psychological Association (APA). He is a
guest lecturer at Sri Lankan and North American universities.
References;
Goonetilleke,G.
(2022) The Extra Mile: a surgeon’s experiences. Sri Lanka
Jayatunge , R.M.(2015). Shell Shock To Palali
Syndrome: Post-Traumatic Stress Disorder Sri Lankan Experience. Godage
International Publishers, Sri Lanka.
Jeffrey SJ. Antipersonnel mines: who are
the victims? J Accid Emerg Med. 1996 Sep;13(5):343-6. doi:
10.1136/emj.13.5.343. PMID: 8894863; PMCID: PMC1342772.
Mannion, S.Chaloner, E. (2006). Chapter 1
Landmines and Landmine Injuries: An Overview, Pain Medicine, Volume 7, Issue
suppl_2.Pages S199–S200, https://doi.org/10.1111/j.1526-4637.2006.00234_3.x
McIvor Joss
D. Anti-personnel landmine injuries: a global epidemic. Work.
1997;8(3):299-304. doi: 10.3233/WOR-1997-8310. PMID: 24441894.
