Death and Injury From Landmines and Unexploded Ordnance in Afghanistan

Context Afghanistan is one of the countries most affected by injuries due to landmines and unexploded ordnance.

Objective To understand the epidemiological patterns and risk factors for injury due to landmines and unexploded ordnance.

Design and Setting Analysis of surveillance data on landmine and unexploded ordnance injuries in Afghanistan collected by the International Committee of the Red Cross in 390 health facilities in Afghanistan. Surveillance data were used to describe injury trends, injury types, demographics, and risk behaviors of those injured and explosive types related to landmine and unexploded ordnance incidents.

Participants A total of 1636 individuals injured by landmines and unexploded ordnance, March 2001 through June 2002.

Results Eighty-one percent of those injured were civilians, 91.6% were men and boys, and 45.9% were younger than 16 years. Children were more likely to be injured by unexploded ordnance (which includes grenades, bombs, mortar shells, and cluster munitions), whereas adults were injured mostly by landmines. The most common risk behaviors for children were playing and tending animals; for adults, these risk behaviors were military activity and activities of economic necessity (eg, farming, traveling). The case-fatality rate of 9.4% is probably underestimated because surveillance predominantly detects those who survive long enough to receive medical care.

Conclusions Landmine risk education should focus on hazards due to unexploded ordnance for children and on landmine hazards for adults and should address age-specific risk behaviors. Expanding community-based and clinic-based reporting will improve the sensitivity and representativeness of surveillance.

Landmines and unexploded ordnance pose a significant public health risk and economic threat worldwide.^1,2 Approximately 60 million to 70 million landmines are placed in about 70 countries,³ and an estimated 24 000 individuals, mostly civilians, are killed or injured by landmines and unexploded ordnance worldwide every year.⁴ Unexploded ordnance includes military explosive munitions such as grenades, bombs, mortar shells and cluster munitions, which have been deployed or scattered during military activities but have failed to detonate.

During 2000 and 2001, Afghanistan had the most reported landmine and unexploded ordnance casualties in the world.⁵ Most of the 7 million to 8 million landmines in Afghanistan were laid during the Soviet occupation between 1978 and 1989 and the subsequent civil war.³ The coalition air strikes in the fall of 2001 exacerbated the problem by deploying a new type of ordnance—cluster bomblets.^5,6 Because the bomblets were bright yellow, concerns existed that children might mistake them for the humanitarian daily rations airdropped during the early stages of the conflict. Another feature of recent conflicts in Afghanistan and Iraq has been the aerial bombardment of munitions dumps. This resulted in scattering of explosives over wide areas. In such situations, injuries due to unexploded ordnance may be as much of a public health threat as those due to landmines.

We undertook this study to evaluate landmine and unexploded ordnance injury surveillance in Afghanistan, to document the magnitude of these injuries and deaths between March 2001 and June 2002, and to describe epidemiological patterns of and risk factors for injury.

We obtained data on landmine and unexploded ordnance casualties from March 2001 through June 2002 from the International Committee of the Red Cross. Duplicate entries were excluded, and statistical analyses were performed using JMP software (Release 5.0, SAS Institute Inc, Cary, NC).

These data were obtained from a clinic-based surveillance system operated by the International Committee of the Red Cross. There are an estimated 905 functioning health facilities in Afghanistan.⁷ Among these 905, the International Committee of the Red Cross identified those facilities most likely to see injuries caused by landmines and unexploded ordnance. These include major referral hospitals, provincial and district hospitals, specialized surgical or rehabilitation clinics, facilities supported by nongovernmental organizations, and basic health centers in areas contaminated by landmines or unexploded ordnance. The current surveillance system includes 390 clinics and hospitals throughout the country⁸ and is believed to include most facilities likely to see injuries due to landmines and unexploded ordnance. Not included in the system are specialized facilities, such as tuberculosis or malaria treatment centers, facilities located in areas with no known landmine or unexploded ordnance problems, facilities in which access is difficult or the situation is insecure, and facilities not wishing to participate in the system.

Surveillance uses a standard data collection form compatible with the Information Management System for Mine Action, recommended and widely used by the United Nations Mine Action Service worldwide.⁵ Those sustaining injuries from landmines and unexploded ordnance, or their family members, are interviewed by trained staff at the health facility, and the forms are forwarded to International Committee of the Red Cross headquarters in Kabul each month.

As participating health facilities were considered neither a random nor representative sample of all health facilities in Afghanistan, the injuries detected are likewise not considered representative of all relevant injuries. Nonetheless, for participating facilities, reported injuries are considered a complete list of all injuries due to landmines and unexploded ordnance seen in those facilities. For these reasons, measures of precision, such as confidence intervals, were not calculated nor was hypothesis testing performed to test the statistical significance of differences between subgroups. Therefore only substantial observed differences between subgroups are highlighted in this article.

This analysis is based on data on 1636 individuals injured by landmines and unexploded ordnance. An average of 102 new injuries were reported each month; the lowest number was reported in October 2001 (Figure 1). A pronounced increase in injuries from unexploded cluster munitions began in October 2001, when the conflict began between the Taliban government and coalition forces. Cluster munitions are weaponized containers that are intended to break open in mid air and disperse smaller munitions or submunitions that are intened to explode just before or at impact.

Forty-six percent of those injured were younger than 16 years. The highest number of injuries was seen among those aged 7 to 15 years. Reported injuries in all age groups were mostly among males (91.6%) and civilians (81.2%) (Table 1).

Children were more likely to be injured by unexploded ordnance; injuries among adults were caused predominantly by landmines. The case-fatality rate was 9.4% and varied little across the age groups (Table 1).

Among injuries to children and adolescents younger than 16 years for whom activity was known, playing and tending animals were the most common activities, accounting for 49% of injuries. Military activity, traveling, and farming were the most common risk behaviors among persons 16 years or older. About 11% of those injured, mostly adults, reported that they knowingly took the risk of going into a dangerous area. About 11% of injured persons reported having received some landmine risk education before the injury (Table 1).

A stratified analysis assessed the relationship of age and activity to explosive type. For each of the activities of economic necessity (ie, farming; tending animals; traveling; collecting wood, food, or water), children were more likely to be injured by unexploded ordnance and adults were more likely to be injured by landmines. On the other hand, both children and adults injured while playing or tampering with explosives were injured predominantly by unexploded ordnance (Table 2).

The results of this study demonstrate that landmines and unexploded ordnance remain a serious public health threat in Afghanistan. As has been seen elsewhere during postconflict periods,^9-11 most of the injured are civilians, with children and adolescents being at highest risk. In addition, surveillance data presented in this report concern only acute injuries and do not address long-term physical disability and mental health concerns, which may add substantially to both the economic and public health burdens.

Furthermore, as our data show, because landmines and unexploded ordnance seriously hinder the simple activities of economic necessity, they may substantially undermine postconflict recovery. The most important risk factors in adults (besides military activity) were activities of economic necessity: farming, tending animals, traveling, and collecting food, wood, and water. However, this risk is not limited to adults. Afghan children begin to be involved in herding at a relatively young age; this is reflected in our data, which show that 13% of injured children aged 6 years or younger and one quarter of injured children aged 7 to 15 years were injured while involved in this activity. These children may be at particularly high risk if herding prevents them from attending school because many landmine risk education programs targeted toward children are school-based. Special programs focusing on children engaged in herding and not at school may be necessary.

Although prior reports and world opinion often pay greater attention to landmines, our data show that more than half of all injuries and deaths in Afghanistan were caused by unexploded ordnance rather than by landmines. Injuries from unexploded ordnance were more prevalent in children and adolescents younger than 16 years, regardless of risk behavior. Because unexploded ordnance are more visible than landmines, unexploded ordnance–related injuries are preventable and should become a priority in landmine risk education efforts.

The proportion of persons who reported knowing that the area was dangerous, that the area was marked for landmines and unexploded ordnance, or that they had received mine risk education was low. However, using these results to evaluate mine risk education is difficult because no estimates exist of the coverage of mine risk education in the general population to permit calculation of injury rates among persons who did and did not receive such education. A rigorous evaluation of the effectiveness of landmine risk education in reducing injuries due to landmines and unexploded ordnance is needed in Afghanistan and other countries.

The surveillance system detected an increase in injuries from cluster munitions during October 2001, which coincided with the start of bombings by coalition forces. This increase gradually subsided after February 2002. These data are consistent with reports about increased danger to civilians from unexploded cluster bomblets.⁶ The decrease in such injuries may be attributed in part to rapid clearance response measures undertaken by the Mine Action Center for Afghanistan after receiving information from the US military about the location of coalition bomb strikes.⁵

The results of this study are subject to several important limitations. The actual numbers of those injured and killed by landmines and unexploded ordnance in Afghanistan are likely to be substantially higher than that reported by surveillance data because the clinic-based surveillance system is likely to miss those who die before reaching a clinic, those whose injuries are too minor to seek medical care, and those living in areas with little or no access to health facilities that are involved in the surveillance system. Because many fatal injuries are probably missed, a case-fatality rate of 9.4% derived from surveillance data is likely to be substantially underestimated. Previous studies using population survey methods found a case-fatality rate of 55% in Afghanistan,¹² 41% in Bosnia,¹² 42% and 48% in Mozambique,^12,13 and 31% in Cambodia.¹²

Time trends in injuries seen in the surveillance data should be interpreted with caution because of low sensitivity and differential system coverage over time. For example, the low number of injuries recorded during September and October 2001 may be due in part to disruption of surveillance activity before and during the coalition strikes.

The disproportionate number of injuries among men may be because women in Afghanistan are more restricted than men in their mobility and thus are less likely to engage in activities that put them at risk for landmine or unexploded ordnance injuries. In addition, some of this observed sex disparity may result from decreased likelihood of injured females to receive medical care or to be interviewed and recorded by the surveillance system.

The absence of reliable data on the age distribution of the Afghan population did not allow for calculating age-specific injury rates. However, by conservative estimates it is unlikely that the group of 7- to 15-year-olds accounts for more than 25% of total population. Therefore, the finding that 40% of all injuries occurred in this age group suggests that this group may indeed be at higher risk.

Expanding clinic-based surveillance to include nonparticipating health facilities would allow recording of more injuries, thus further increasing sensitivity. Using alternative methods for data collection, such as community-based surveillance or population-based surveys would allow for recording more representative data, including fatal and minor injuries, and injuries among women and girls.

Surveillance data suggest that landmine risk education should focus on landmine avoidance among adults and avoidance of unexploded ordnance among children and adolescents. Surveillance data from Iraq and other countries where munition dumps have been bombed may show a similar need to focus mine risk education programs on the risks of unexploded ordnance injury as much as landmine injury, particularly among children.