This article details the introduction and key findings of AOAV’s examination of the health impacts from explosive violence. The full report, Blast injury: the reverberating health impacts from the use of explosive weapons, can be found here.
Over 338,000 people have been killed or injured by explosive violence in the last nine years. This, at least, is data from Action on Armed Violence (AOAV)’s explosive violence monitor of English language media. Of these, at least 251,000 have been civilians; 74% of total casualties. However, the impact of explosive weapons stretches far beyond the immediate blast and casualties, as research into the reverberating effects of explosive violence by Action on Armed Violence (AOAV), Save the Children, Article 36, Humanity and Inclusion, and others has shown.
While the health consequences of conflict have long been a concern, it is only recently that there have been increased awareness of the need for more research into the specific health impacts of explosive weapons on their direct and indirect victims.
AOAV’s latest report seeks to analyse, summarise and expand on this research. It does so by focusing on four key areas where explosive violence impacts health systems. We examine, in turn, the physical impacts; the psychological impacts; infrastructural and personnel damage and disruption; and end on a review of access to healthcare. Both the direct and indirect health impacts from the use of explosive weapons are considered throughout.
The report seeks to illustrate some key health concerns that arise from explosive weapon use by focusing on two on-going conflicts: the conflict in eastern Ukraine which began in 2014; and Syria’s nine-year-long conflict, which began in 2011.
In Ukraine, the conflict is located in the eastern part of the country, involves few actors and sees predominantly shelling, landmines and victim-activated improvised explosive devices (IEDs). In Syria, conflict has been seen across the country at various times and, due to high numbers of both state and non-state actors involved, the variety of weapon types has been considerable. These have included cluster munitions and improvised air-dropped bombs, such as barrel bombs used by regime forces and improvised air-dropped munitions by ISIS. Both conflicts have caused significant harm to the health of local populations and have had reverberating and ongoing deleterious impacts on healthcare in their own and other countries.
- Explosive violence results in countless immediate casualties, especially when these weapons strike populated areas
- AOAV recorded more than 251,000 civilian casualties from explosive weapons globally between 2011-2019. This consisted of 89,000 civilian deaths and 162,000 injuries.
- The injuries caused by explosive weapons are complex and often require multiple operations and lifelong care
- A study of blast casualties in a Médecins Sans Frontières hospital in Syria’s Raqqa found that 42% of blast-related injuries involved soft-tissue damage; 22% involved open-fractures; 11% were torso injuries; and 11% were traumatic amputations. Most patients had multiple traumatic injuries.
- The living conditions as a result of explosive violence also contribute to illness and disease
- In one week of early February 2020 alone, dozens of children perished due to the terrible conditions within the displacement camps in Syria’s Idlib.
- Much of the data and studies of blast injury stems from developed healthcare systems and focuses on fit able-bodied males
- Much of the data cannot be applied in the civilian settings, particularly in the developing country context or in countries whose healthcare infrastructure has been devastated by conflict
- The exposure to explosive violence appears to contribute to a range of mental health concerns beyond post-traumatic stress disorder
- In the conflict-affected areas of Ukraine, 40% are said to have experienced trauma resulting in stress, depression, anxiety, and post-traumatic stress disorder.
- Those that have been injured by explosive weapons are significantly more likely to develop mental health concerns
- A Humanity and Inclusion study found that 80% of people injured by explosive weapons in Syria expressed signs of high psychological distress.
- Many of the mental health impacts from explosive violence may also stem from the reverberating consequences of explosive weapon use such as displacement
- Among Lebanon’s Syrian refugees, it was reported that in many cases the psychological impacts often stem more from the reverberating consequences of explosive violence, such as displacement and poor living conditions.
- Often the communities hosting war-impacted persons are not equipped to cope with the level of mental health support needed
- In Lebanon there are just 50 psychiatrists, including 3 child psychiatrists, and they struggle to cope with the needs of the Lebanese, let alone the Syrian refugees too
Infrastructure and personnel
- Hospitals are all too frequently hit by explosive weapons in conflicts
- Between 2011 and 2019, AOAV recorded 3,447 civilian casualties from the use of explosive weapons in 221 attacks on hospitals. Such attacks were recorded in 23 countries from Afghanistan to Ukraine to Peru.
- While such facilities should be protected, healthcare facilities frequently targeted or otherwise hit in attacks
- Of 600 primary health care facilities in Luhansk and Donetsk oblasts, over 35% of them have sustained damage.
- While health professionals often stay behind to assist the remaining populations, eventually most are forced to flee explosive violence, resulting in low numbers of professionals available to meet the needs of the populations
- In Ukraine, the most significant decreases in the number of full-time doctor positions between 2012 and 2016 were observed in territories that witnessed the fiercest fighting, namely: Avdiivka (a 23% decrease); Mariinka (15%); and Yasynuvata (14%).
- The health professionals that remain do so at considerable risk and frequently become victims of the violence
- Physicians for Human Rights estimate that, by March 2020, at least 923 medical professionals had been killed in the conflict in Syria.
- Explosive violence not only reduces the level of healthcare available but also makes it more difficult to reach due to transport difficulties, cost consideration and safety.
- Among families within 20km of the contact line in eastern Ukraine, 40% face significant challenges accessing healthcare services.
- The cost of healthcare is often a significant barrier for the displaced and refugees who will often have little to no income to rely on.
- In one survey of IDPs in Ukraine, those who had paid for care in the 12-months prior to the questionnaire had an average bill of $107.
- Psychological support was frequently cited as difficult to access
- Of 120 Syrian refugees AOAV surveyed across Lebanon, 86% of those who answered had not been offered psychological support.
- There are also gender barriers to access, often due to cultural and religious norms, though some have taken steps to address this barrier
- Of the 3,000 rescue workers that volunteer for the Syrian Civil Defense (the White Helmets) less than 5% are women – nevertheless, this increase female rescuers is said to have helped in the rescue of female casualties
AOAV carried out desk-based research, as well as interviews and on the ground investigations in Ukraine and at the Syrian border in Lebanon. Interviews were conducted with healthcare workers, academics, NGO personnel, civilians and other experts. 120 surveys were conducted among the refugee population in Lebanon focused on access to healthcare. The results of this survey are discussed throughout. The data on explosive weapons comes from the Explosive Weapons Monitor Project. For the methodology please see our latest Explosive Violence report.
The full report, Blast injury: the reverberating health from the use of explosive weapons, can be found here.
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