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Each year landmines kill and maim an estimated 26 000 people worldwide.1 About 10%–40% of these victims are children, most of whom are affected long after the cessation of hostilities.2,3 These deaths and injuries are potentially preventable but planning measures are hampered by the lack of data on determinants of landmine injuries in children; consequently mine awareness programmes for children are routinely designed using adult data.4 To overcome this gap, we have studied the determinants of landmine related injuries in Bosnia and Herzegovina during 1991–2000, and compared children with adults.
SUBJECTS, METHODS, AND RESULTS
Since 1996, the International Committee of the Red Cross (ICRC) and the Red Cross Society of Bosnia-Hercegovina have maintained an active surveillance system for collecting data on mine related injuries.4 Red Cross field workers based in each municipality (n=128) actively seek out any reports of mine related incidents through local information, hospitals, and organisations involved in such activities. Each report is followed up by a personal visit to the victim’s household by the field worker who then completes a standardised questionnaire. These questionnaires are returned monthly and entered on the ICRC database in Sarajevo. The database is validated by reports from other sources involved in mine related activities. Data for post-war years (1996–2000) were collected prospectively and are complete while that from the war years (1991–95) are retrospective data likely to be incomplete in coverage. It is impossible to validate data from the time of conflict.
From this database, we retrieved data on determinants of landmine injuries for all the victims of landmines during the period 1991–2000. Data retrieved were broadly under the categories of demographic data, knowledge and background of the victim, nature of the device, timing and activity at the time of the injury, and outcome of the incident. Data on all the determinants were used as such except one relating to activity at the time of incident, which was categorised into three groups on the basis of potential for modification by mine awareness activities: (a) preventable (modifiable)—leisure and handling device out of curiosity; (b) partially preventable (partially modifiable)—economic, returnee, and mobility activity; and (c) non-preventable (limited potential for modification)—de-mining and military/police activity. We analysed the data by carrying out simple comparisons of proportion of children and adults affected for each of the determinants; children were defined as those under the age of 18 years. Statistical significance for these comparisons was tested by χ2 tests using the statistical package Stata version 6.0.
There were 4064 victims of mine related injuries reported to the ICRC overall (1991–2000), of which 549 (14%) were children. Children were more likely to be injured during peacetime as compared with adults (children: 50%, adults: 26%; p<0.001), see figure 1. Greater predisposition for male sex and spring season were determinants common to both adults and children; however, children differed significantly from adults in their knowledge of the nature of the device and the site being mined, and in the incident being considered “preventable”. By far the commonest activity for children at the time of incident was recreational (44%), unlike adults who were involved in military/police activities (48%). Children are also more likely to be killed or injured in groups than adults (table 1).
This study highlights important differences between children and adults in the determinants of landmine related injuries, including a large modifiable behavioural component. Marking of mined areas, information, and mine awareness need to begin very early in the peacetime when sudden freedom of movement results in a large number of injuries. Preventive programmes need to be tailored appropriately for children with greater emphasis on knowledge of non-classic explosive devices. Such programmes also need to be more active in early springtime possibly targeting boys more than girls. Clearly identified safe play areas and addressing group behaviour are important as most incidents in children follow recreational activities in groups.
Anti-personnel landmine associated mortality and morbidity in children remains one of the unmet challenges of preventative medicine despite significant potential for saving years of life lost and disability. A total ban on landmines is welcome; however, at the present rate it would still take a long time to clear the existing landmines today.5 Greater commitment and resources from the international community are required to expedite this important public health measure. In the meantime, there is an urgent need for effective and multifaceted public health strategies, covering elements of mine awareness, education, and health services, to safeguard children living with mines. Above all, these strategies will need to be focused by using accurate and recent local data to make best use of limited resources.
We are grateful to The International Committee for the Red Cross (ICRC), Sarajevo, for making the dataset available to us for analyses. However, the views expressed in this paper are of the authors alone and do not necessarily reflect the views of their respective organisations or ICRC.
Conflicts of interest: none.