Physical and Psychological Impact of Land Mine Injuries in Sri Lanka

 

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.