This article is part of AOAV’s examination of the health impacts from explosive violence. The full report, Blast injury: the reverberating health from the use of explosive weapons, can be found here. The summary and key findings can be found here.
- 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.
- 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.
- By 2016, the mortality rates in the war-torn Donetsk region of Ukraine were more than double the birth rate.
- 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.
Between 2011 and 2019, AOAV recorded more than 251,000 civilian casualties from explosive weapons, as recorded in English language news media around the world. This figure breaks down into 89,000 civilian deaths and 162,000 injuries: overall, an average of ten civilian deaths and injuries were recorded from each explosive incident.
These reported figures might, however, just be the tip of an iceberg. As recent AOAV research has shown, not only do some explosive incidents go unreported, but injuries are also less likely to be reported than deaths. As such, the true figure of civilian casualties from explosive violence is likely to be even higher than the data from AOAV’s Explosive Violence Monitor suggests. Reported casualties also rarely include invisible injuries, such as traumatic brain injury (TBI), despite its seriousness and prevalence.
Beyond the immediate impact of the blast there are, of course, other long-lasting health implications. The injuries caused by a blast, from damage to the victim’s hearing or vision, to limb amputation and everything in between, will often need lifelong treatment and may lead to further health complications of their own. For example, an amputation may increase an individual’s chance of developing arthritis. However, many of these reverberating health impacts remain under-examined or addressed, particularly in low and middle-income countries.
Some academic researchers and organisations have identified the common injuries associated with explosive weapons, such as Humanity and Inclusion and Save the Children. In 2019, for instance, Imperial College released a field manual to address paediatric blast injuries – highlighting how little understood and examined this tragic subsection of harm really is.
One of the main concerns among health professionals is the lack of data and research on the lasting impact of blast injuries among civilian populations. Dr Ghassan Abu-Sitta, head of Plastic and Reconstructive Surgery at the American University of Beirut Medical Centre, told AOAV that relatively little is known about traumatic brain injuries from blast among civilian populations. Equally, data on war-wounded children treated in conflict zones is sparse.[i]
Today, most data on the long-term health complications that arise from explosive weapon harm comes from the Veterans Affairs (VA) system in the US. But such data, whilst useful, has its limitations. It mostly focuses on previously fit, young, adult males who, from the moment of injury were triaged and managed through a highly-developed, well-funded medical system. Much of this knowledge, then, cannot be applied to civilian injuries that occur in under-resourced conflict environments. And it does not really help in understanding the impact of explosive violence on children, the elderly, those with underlying health conditions, or give a nuanced understanding of the gendered differences in health outcomes.
Dr Abu-Sitta also advocates for a more comprehensive view of war injury. “What we understand is that wars actually create an ecology”, he told AOAV. “And that ecology of war traps people inside it; it injures them in ways that we don’t recognise immediately as war injuries but these are as a result. For example, a child who suffers a burn in a refugee camp that’s a result of living in unsafe housing, not a war injury, but it is a consequence of the ecology that war itself has created.”
To address this, in this section, AOAV examines not only the direct physical impacts from explosive weapon use in Syria and Ukraine, but also looks at the indirect physical impacts the ecology of explosive violence in war creates.
AOAV recorded more than 2,600 civilian casualties from explosive weapons in eastern Ukraine between 2014 and 2019. Since 2014, over 1,000 civilians have been killed or injured by landmines and UXO in the region. In total, over 3,000 civilians are thought to have been killed in the Donbas region alone.[ii] Another 30,000, both civilians and armed actors, have been wounded, including between 7,000 and 9,000 civilians. Of the civilian casualties AOAV has recorded in the country, at least 88% were due to ground-launched explosives, mostly shelling, and 6% were caused by landmines and IEDs.
The conflict in eastern Ukraine is one that revolves around a frontline and which is occurring in an area of the country. This means it is easier for civilians, especially those who are young and able-bodied, to seek refuge in another area. This, in part, has resulted in fewer civilian casualties in the most recent years of the conflict.
In 2014, AOAV recorded 1,428 civilian deaths and injuries from explosive weapons in Ukraine and 862 the year after. The following years saw significant decreases. In 2019, AOAV recorded 61 civilian casualties. Though this doesn’t include those from UXO, it is a significant indication of the fall in civilian casualties from explosive weapons.
Eastern Ukraine is one of the most mine-contaminated places in the world; today, two million people in eastern Ukraine remain at risk of death or injury from landmines and other explosive remnants of war. Such injuries require lifelong care.
In Syria, AOAV recorded more than 74,500 civilian casualties from explosive weapons between 2011 and 2019, including 32,000 deaths and 38,500 injuries. These figures strongly suggest that injuries are being significantly underreported.
A study of blast casualties in an MSF hospital in Raqqa gives an idea of the most common injuries from explosive weapons. 42% of blast-related injuries involved predominantly soft tissue damage; 22% of cases involved open-fractures; 11% of patients had torso injuries and traumatic amputations, respectively. Other common injuries included closed fractures, cranial injuries, vascular injuries, eye injuries, spinal injuries, degloving, and burns. Most patients had multiple traumatic injuries.
The MSF study examined patients both in the offensive and post-offensive period and, while the types of injuries were similar, the post-offensive patients saw higher rates of multiple traumatic injuries. Post-offensive patients also saw higher rates of infection – this could be due to the likelihood of explosives being among debris or in the ground, causing dirt and detritus to become embedded in the wounds. During the offensive, there were higher rates of surgical or anaesthetic complications.
The gender and age distribution changed significantly over time too, with far higher levels of males as a percentage of casualties in the post-offensive period than the offensive. This is likely to be an indication that initial returnees were often males, or that those among the returnees carrying out dangerous work, such as rubble clearance or explosive clearance, were males. In the offensive period, females accounted for 32% of patients and children for 42%.
Syria has been an exceptionally dangerous conflict for children due to the use of explosive weapons. A study carried out by Save the Children, published in 2019, found that 72% of child casualties in the five most deadly global conflicts were injuries caused by explosive weapons,. In Syria, 83% of children physically harmed in the war were injured by explosive weapons.
A report by UNICEF in 2018 estimated that 1.5 million Syrians were living with permanent, war-related impairments. Of these, 86,000 people had receive injuries that had resulted in amputations.
Such injuries in Syria often require life-long expert health care. Unfortunately, not only do explosive weapons result in catastrophic injuries, they also decimate healthcare systems, meaning such support is often thin on the ground. Due to displacement and other conflict-related restrictions, many wounded may not receive adequate care. Even when they do, poor living conditions mean the injured often have high rates of readmission from complications such as infection and disease. Dr Nada Awada, a Senior Medical Advisor at IMC in Lebanon, told AOAV that the poor quality of housing and living environments faced by Syrian refugees throughout Lebanon often led to post-surgery complications.[iii]
Some healthcare organisations try to take preventative steps when faced with such realities. The ICRC in Lebanon provides rehabilitation in their onsite facilities, so as to ensure individuals recover in a hygienic environment and thereby reducing the risk of infection. But such provision is limited – the post-surgery living conditions for many in the most impacted areas in Syria is dire and invariably leads to significantly worse long-terms health outcomes.
Limited healthcare access also brings its own problems. In Syria and Lebanon, there is little in the way of antibiotic stewardship and many patients either self-adminster or fail to take antibiotics correctly. 70% of Syrians are said to show multiple drug resistance to common antibiotics.[iv] In addition, antimicrobial resistance especially impacts those who have experienced blast injury. In Lebanon, this leads to a high prevalence of urinary tract infections (UTIs) among the refugee population.[v]
The use of explosive weapons causes other, indirect, physical health impacts. These can be a consequence of a shortage of medicines and healthcare staff; underlying health conditions not being diagnosed in the maelstrom of war; complications or advancing disease in people suffering existing health issues, such as missing cancer treatment or necessary operations; and a raft of other conditions brought on by those companions of conflict – depression, malnutrition and insecurity.
In Ukraine, more than 1.4 million civilians remain displaced. Internal displacement and food shortages – largely a consequence of the shelling, UXO and other violence – contribute to health concerns. In this part of the world, the high percentage of elderly civilians and a relatively high proportion of people living with disability in the conflict-affected areas, also exacerbates the impacts of war. The elderly are so omnipresent in the east of Ukraine that the conflict has been dubbed ‘the oldest war in the world’.
Donbas, for instance, had the highest rate of elderly in Ukraine even before the conflict began. About 30% of the 3.4 million people requiring humanitarian aid because of the violence in the region are of pension age – the highest rate of all global conflicts. Today, between 50 and 70% of the population in Ukraine’s conflict-affected areas are elderly. Furthermore, about 60% of pensioners in the non-government-controlled areas are receiving no pension. Elderly in the region have described how they have to choose between medicine and food, and half of people living with food insecurity in eastern Ukraine are thought to be elderly. In addition, as many as 97% of older people are said to have at least one chronic condition, in a place where access to healthcare is limited.[vi]
About 30,000 people cross the contact line between the occupied and government territories every day – in blistering summer heat and in the desolate cold of winter. Such journeys are a necessity for many elderly – they must make the journey so as to collect their pensions. The NGO Right to Protection has estimated that 48% of those crossing checkpoints were aged 60 and above.[vii]
As AOAV has witnessed, the queues to the checkpoint are long and merciless: it can take hours for a 70 year old to make the journey. To avoid losing their place in the queue, many neither eat nor drink so they don’t need to use the toilet. There is a walk of up to 3km between checkpoints, and land on both sides is mined and is subjected to sporadic fighting and shelling. It is no wonder that some die in the crossing. The NGO ‘Right to Protect’ recorded 35 deaths at checkpoints between January and September 2019 alone; almost all were elderly and most died of heart-related complications. When AOAV meet with the team at the Mayorsk checkpoint, in the space of half an hour, the team was mobilised twice; once to respond to a woman who had fainted and the other to help reduce a man’s elevated heart rate.
Beyond checkpoints, an endemic lack of supplies and access to healthcare is thought to have contributed to a higher infectious rates of HIV and tuberculosis – ones that have sharply risen since 2014. Rates of tuberculosis, for instance, are reported to have increased by 54% in Donetsk in recent years. Soldiers, too, bring sexually transmitted diseases with them, all too often.
While rises in some diseases and illnesses are related to the lack of healthcare due to the ongoing fighting, others are related to the stress caused by shelling and violence. When AOAV visited the main hospital in Popasna, a city in the Luhansk Oblast (region) of Ukraine, the director described seeing ten times the number of diabetes-related amputations than pre-war levels. Other spikes in illnesses included cardio-vascular diseases and diabetes, confirming the findings of other studies.
Dr Alexandr Vladimirovych Kovalchuk said these spikes were caused by the stress of the conflict along with “a lack of medical monitoring of displaced peoples; patients presenting with more advance diseases; a rise in people presenting with endocrine issues; a rise in oncological diseases; poor nutrition; poor quality drinking water; a lack of employment opportunities; alcoholism; a lack of secure accommodation.”
Other doctors at Popasna highlighted a significant issue seen across all conflict zones: many conditions would have been caught much earlier in a peaceful region.
Such health consequences, as well as the damage to health infrastructure and a reduction in healthcare access, influenced mortality rates in the most impacted regions. In a report undertaken by the Deputy Chief of Healthcare Statistics in the Donbas region, it was found that, by 2016, the mortality rates in the Donetsk region had far outstripped the birth rate. The birth-rate was at 7.05 per 1,000, while mortality rates stood at 16.4 per 1,000. Those areas with the highest birth-death rate disparity had also been witness to the fiercest fighting.
Those living in impacted areas, as well as the displaced, often find themselves living in conditions so bad that poor health outcomes become a terrible certainty. Health professionals that AOAV met in Lebanon, said living conditions were one of the primary causes of illness and injury among Syrian refugees in the country. Alongside considerable food insecurity, communities also saw a rise in unhealthy eating habits, as families fell back on cheap, highly processed. There was a notable and widespread lack of nutritional food available, and poor conditions to prepare healthy, wholesome meals.[viii] Additionally, due to the growing economic insecurity in Lebanon, the money families have to spend on food is shrinking. Limited funds mean, for many, prioritising food over hygiene items too, increasing the risk of illness.
Certainly, life there is terrible for so many refugees. AOAV met residents at one informal camp where the tents stood next to a large, filthy pool of stagnant water. Sometimes it flooded their camps, washing rubbish and human waste through their spartan homes. Biting insects and bedbugs were aplenty. Colds and flus spread through the camps like wildfire, too. And, in a time of COVID-19, such unhygienic and grim conditions offer a terrible breeding ground for infection.
The extent of such harm is hard to quantify. Already in Lebanon, Iraq and Syria, the numbers of Covid 19 cases are believed to far exceed official figures. The spread of the virus in Syria seems impossible to control. In Idlib, for example, camps already stand at 400% overcapacity. Spare hospital beds or ventilators are a luxury rarely seen.
Other health threats and dangers persist. Previous research by AOAV on the reverberating harm from explosive weapons in Syria found links between this violence and rises in waterborne diseases and respiratory illnesses, as well as a sharp drop in immunisations for children.
In Syria, in particular, there has also been a concerted effort to disrupt food supplies through the use of explosive weapons, whether through damaging agricultural infrastructure or breaking supply routes and targeting markets. AOAV has recorded more than 100 incidents of explosive violence on markets in Syria – a figure that doesn’t even include bombardments that hit multiple sites including markets.
Two-and-a-half million people, or 10% of the pre-war Syrian population, have been victims of sieges. As a consequence, near-famine conditions have been widespread since the outbreak of conflict. In December 2017, UNICEF reported that 11.9% of children in Eastern Ghouta were suffering from acute malnutrition. This tactic of starvation continued unabated in Idlib throughout 2019 and 2020. In July and October 2019, the UK’s Channel 4 News published two reports; the first focused on children scavenging through rubbish for food in Idlib, the second examined the strategic bombardment and burning of farmland by the Syrian army to starve opposition and the populations in these ares into submission.
In 2020, food insecurity in Syria remains at critical levels, a reality compounded by the total collapse of the Syrian currency and by ongoing sanctions imposed by foreign powers. According to the International Rescue Committee, the recent Idlib offensive triggered “the largest displacement in the country’s nine-year-old war”, with one million people estimated to have been displaced. In one week of early February 2020 alone, dozens of children perished due to the terrible conditions within the displacement camps, a death toll exacerbated by the lack of access to food and medicine.
Syria Relief and Development, a charity supporting Idlib’s internally displaced persons (IDPs), have warned that famine on the scale of the one in Yemen could hit northwest Syria. Such levels of malnutrition may have a severe impact on future Syrian generations.
It is clear, then, that explosive weapons not only cause
lasting direct health problems. The indirect impact can be just as lasting and
damaging to the health of local populations as well as those internally
displaced and forced to become refugees. Much of this lasting harm depends on the
local ability to access healthcare, including the capacity of local
infrastructure and personnel to provide healthcare. To such concerns we turn
[i] Interview with Dr Ghassan Abu-Sitta, head of Plastic and Reconstructive Surgery at the American University of Beirut Medical Centre, January 31st 2020.
[ii] Buckley, C. et al. 2019. ‘An assessment of attributing public healthcare infrastructure damage in the Donbas five years after Euromaidan: implications for Ukrainian state legitimacy’, Eurasian Geography and Economics, DOI: 10.1080/15387216.2019.1581634.
[iii] Interview with Dr Nada Awada, Senior Medical Advisor at IMC, January 28th 2020.
[iv] Interview with Dr Ghassan Abu-Sitta, head of Plastic and Reconstructive Surgery at the American University of Beirut Medical Centre, January 31st 2020.
[v] Interview with Natalia Garland, MAPS, January 31st 2020.
[vi] HelpAge, ‘Humanitarian needs of older women and men in government-controlled areas of Donetsk and Luhansk oblasts, Ukraine’, July 2018.
[vii] Right to Protection, ‘Monitoring of the Implementation of the MTOT Order No 39 on approval of the list and volumes of goods allowed to be moved to/from humanitarian and logistics centers and across the line of contact’, 2019.
[viii] Interview with Dr Lamis Jomaa, assistant professor at the Faculty of Agricultural and Food Sciences at AUB, January 31st 2020.
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