Social cost of land mines in four countries: Afghanistan, Bosnia, Cambodia, and
Mozambique
Neil Andersson, Cesar Palha da Sousa, Sergio Paredes
Abstract
Objectives - To document the effects of land mines on the health and social
conditions of communities in four affected countries.
Design - A cross design of cluster survey and rapid appraisal methods including
a household questionnaire and qualitative data from key informants,
institutional reviews, and focus groups of survivors of landmines from the same
communities.
Setting - 206 communities, 37 in Afghanistan, 66 in Bosnia, 38 in Cambodia, and
65 in Mozambique.
Subjects - 174,489 people living in 32,904 house holds in the selected
communities.
Main outcome measures - Effects of land mines on food security, residence,
livestock, and land use; risk factors: extent of individual land mine injuries;
physical, psychological, social, and economic costs of injuries during medical
care and rehabilitation.
Results - Between 25% and 87% of households had daily activities affected by
land mines. Based on expected production without the mines, agricultural
production could increase by 88-200% in different regions of Afghanistan, 11%
in Bosnia, 135% in Cambodia, and 3 6~/o in Mozambique. A total of 54 554
animals was lost because of land mines, with a minimum cash value of $6-5m, or
nearly $200 per household. Overall, 6% of households (1964) reported a land
mine victim; a third of victims died in dhe blast. One in 10 of the victims was
a child. The most frequent activities associated with land mine incidents were
agricultural or pastoral, except in Bosnia where more than half resulted from
military activities, usually during patrols. Incidences have more than doubled
between 1980-3 and 1990-3, excluding dhe incidents in Bosnia. Some 22% of
victims (455/2100) were from households reporting attempts to remove land
mines; in these households there was a greatly increased risk of injury (odds
ratio 4-2 and risk difference 19% across the four countries). Lethality of
the mines varied; in Bosnia each blast killed an average of 0 54 people and
injured 1-4, whereas in Mozambique each blast killed 1-45 people and wounded
1-27. Households with a land mine victim were 40¡/0 more likely to experience
difficulty in providing food for the family. Family relationships were affected
for around one in every four victims and relationships with colleagues in 40%.
Conclusions - Land mines seriously undermine the economy and food security in
affected countries; they kill and maim civilians at an increasing rate. The
expense of medical care and rehabilitation add economic disability to the
physical burden. Awareness of land mines can be targeted at high risk
attitudes, such as those associated with tampering with mines.
Introduction
The problems of land mines left after armed conflicts have been increasingly
publicised in recent years and are now recognised as reaching crisis
proportions in many countries.[i, ii] At the United Nations' conference in
Geneva in July the Secretary General, Dr Boutros Boutros Ghali, called for a
total ban on the manufacture, trade, and use of land mines, akin to the ban on
chemical warfare.
Immediate action is required to reduce the risks of existing land mines.
Programmes to remove the devices, to increase the awareness of communities, and
to rehabilitate the victims are running in Afghanistan, Bosnia, Cambodia, and
Mozambique. But they are hampered by lack of resources and, sometimes, lack of
knowledge of how best to focus efforts to tackle this plague.
It may cost as little as $3 to produce a land mine[iii] It costs $300-$1000 to
remove one.[iv] Reliable international figures do not exist, but the Red Cross
estimates that land mines kill about 800 people and injure thousands each
month.[v] Victims of land mine blasts often require extensive and prolonged
medica care and rehabilitation, which is not usually available from already
poorly funded and overstretched health services.[vi] Most data on land mine
incidents come from rehabilitation or medical facilities.[vii, viii] But many
victims do not have contact with the services. The worst impact is often on
remote communities in poor countries; many victims die alone and far from help.
An estimated 110 million land mines currently exist on the earth,[ix] and the
number is constantly increasing as the number of new mines laid exceeds the
rate of removal. Several million land mines were laid during the civil
conflicts in Afghanistan, Cambodia, Mozambique, and Bosnia-Hercegovina; in some
of these countries the laying of mines continues. Surveys of communities in
these four countries between May 1994 and March 1995 provided us with a unique
opportunity to investigate the social costs of land mines.
Methods
Information from communities was obtained from Afghanistan, Bosnia, Cambodia,
and Mozambique by means of sentinel community surveillance. The aim of this
approach is to obtain data of priority issues in a way that can be used to
precipitate local preventive actions.[x, xi] A key feature is linkage of
qualitative data with coterminous quantitative data obtained from cluster
surveys. The sentinel communities can be chosen to represent a region or
country, so aggregated survey data can be used for national and regional as
well as local planning.
The sites in Cambodia, Mozambique, and Bosnia were selected by multistage
stratified sampling to be as representative as possible of each country, given
the absence of reliable sampling frames and restrictions on movement. The data
should not be interpreted as a complete national picture. The Afghanistan sites
represent only provinces to which there was ready access. The sample reflected
the situation in three distinct population groups: resident communities, Kuchi
(nomad) bands, and displaced people and refuges in camps.
The same questionnaire, with minor changes to suit each country, was used in
all communities. Questions were asked on whether land mines had caused a change
in residence; the effects of land mines on daily living activities; the numbers
of livestock kept and numbers lost to land mines; the amount of agricultural
land held and reduction in land use because of land mines; food security during
the previous month; attempts to remove land mines; age, sex, occupation, and
education of victims; activities at the time of incidents; medical and
rehabilitation costs; and effects of the injuries on family and work life. The
research team of five to eight interviewers covered all contiguous households
in each site until they had achieved the number assigned for the national
pictures. The statistical handling of this method is discussed in detail
elsewhere.[xii, xiii] Key informants in each community were asked about changes
in agricultural production patterns related to the presence of land mines and
local prices of livestock and farm produce. People who had been disabled by
land mines were recruited in each community to a focus group to delve into the
perceptions of victims.
Data entry, cleaning, and analysis relied on EpiInfo. Risk analysis was based
on sequential stratification using the Mantel-Haenszel procedure.[xiv, xv]
Contrasts are expressed as the odds ratio or risk difference.[xvi] Confidence
intervals are those of Miettinen.[xvii] Heterogeneity between strata was tested
using the procedure proposed by Zelen.[xviii]
Results
The household questionnaire yielded information about 174489 people in 206
communities (table I). In Afghanistan 7% of resident and refugee householders
(502/7273) said that they had been obliged to move or could not return to their
homes because of land mines. In Bosnia some 28% of the population (8749/31246)
was displaced (only a small part of this could be attributed directly to
mines); 22% of those interviewed (6874/31246) said that they occupied
households vacated by "the other side" during the infamous "ethnic cleansing."
In Cambodia 22% of households (1359/6090) and in Mozambique 2% of households
(180/9134) said that they had been forced to leave because of land mines. Many
households reported that their daily activities were affected by land mines,
ranging from 19% (1735/9134) in Mozambique to 78% (1617/2067) in parts of
Afghanistan. Farming, wood cutting, and herding were the activities most
restricted.
| TABLE 1 - Populations studied in the four countries |
| No of households interviewed | Study population | No of sites |
| Afghanistan: |
| Residents | 5184 | 39971 | 24 |
| Nomads | 1432 | 11381 | 6 |
| Refugees | 2089 | 15250 | 7 |
| Bosnia | 8975 | 31246 | 66 |
| Cambodia | 6090 | 33950 | 38 |
| Mozambique | 9134 | 42,691 | 65 |
|
| Total | 32904 | 174489 | 206 |
Without land mines the agricultural land use in the Afghani sample could be
increased by 88%-200% above the currently farmed 71,945 hectares. In Bosnia it
could increase by 11%a further 861 hectares above the 7,556 now cultivated by
our sample. In Cambodia the increase would be about 135% - 6,608 hectares on
top of 4,904 currently cultivated. In Mozambique a 36% national increase over
the 14,179 hectares currently farmed would represent employment for some 10% of
the sample population.
A total of 57,339 animals were reported lost to land mines, with a minimum
local market value of $654,7000 (just under $200 per household) across the
whole sample. In Afghanistan the bulk of the loss was suffered by the Kuchi
(nomads), who reported losses of nearly 35,000 animals; this is an average of
24.4 animals per household, or $2,933 at local market prices.
Except in Bosnia, most households did not have sufficient food in the previous
month, and they had experienced difficulty in providing food for their
families. As might be expected from the most expensive relief operation in
modern history, nearly all of the Bosnian population had received food aid; on
average, households had enough food stored for four months. Across the four
countries, households with a mine victim were 40% more likely to report
difficulty in providing food for the family (odds ratio 14 (95% confidence
interval 12 to 1 6); stratified analysis).
VICTIMS OF LAND MINES
The household study identified a total of 2,100 victims of land mines,
affecting around 6% (1964/32,904) of households overall (table II) . Prevalence
was as high as 22% in parts of Afghanistan. One in three
| TABLE II - Details of land mine accidents in the four countries |
| No of victims | No (%) of households affected | No (%) killed |
| Afghanistan* | 1265 | 1034 (12) | 699 (55) |
| Bosnia** | 195 | 242 (3) | 79 (41) |
| Cambodia | 443 | 432 (7) | 136 (31) |
| Mozambique | 197 | 256 (3) | 83 (42) |
|
| * In only certain provinces. |
| ** May be underestimates because some incidents
were viewed as being of military importance. |
died in the blast. The age and sex specific rates of land mine incidents are
largely explained by the occupation of victims and their activity at the time
(table III). Men of economically active age ( 15 to 64 years) were at highest
risk. Around one in 10 of the victims was under 15 yea old, the highest
proportion of children being in Afghanistan because of their employ ment as
herders. Few of the blasts in Afghanistan, Bosnia, and Cambodia affected women,
but in Mozambique about a quarter of the victims were women.
In Bosnia each blast killed an average of 0 54 people
TABLE III - Age and sex specific rates of land mine accidents.
Values are
numbers of events per 1000 population |
| Age (years) |
| less than or
equal to 14 | 15-44 | greater than or
equal to 45 |
| Afghanistan*: |
| Male | 9.0 | 95.4 | 37.1 |
| Female | 8.0 | 4.5 | 18.1 |
| Bosnia**: |
| Male | 0.7 | 8.1 | 2.3 |
| Female | 0.0 | 0.5 |
| Cambodia: |
| Male | 4.0 | 51.3 | 29.4 |
| Female | 0.4 | 2.3 | 3.7 |
| Mozambique: |
| Male | 1.4 | 14.3 | 10.6 |
| Female | 1.0 | 3.2 | 5.6 |
| * In only certain provinces. |
| ** May be underestimates because some incidents
were viewed as being of military importance. |
TABLE IV - Risk of injury after moving land mines.
Values are numbers of
subjects |
| Afghanistan |
|
| Residents | Refugees | Nomads | Bosnia | Cambodia | Mozambique |
| Those injured by mines: |
| Who removed mines | 191 | 1 | 52 | 12 | 63 | 14 |
| Who did not remove mines | 266 | 165 | 217 | 131 | 402 | 176 |
| Those not injured by mines: |
| Who removed mines | 47 | 0 | 14 | 8 | 29 | 14 |
| Who did not remove mines | 4372 | 1864 | 1149 1125 | 5594 | 8955 |
| Odds ratio* | 4 | - | 1.43 | 5.9 | 6.25 | 50 | /TR>
| Chi-squared,df=l | 74 | 0.1 | 1.32 | 18 | 85 | 317 |
| *Combined odds ratio 4.2 (95% confidence interval 3.6 to 5.6), chi-squared=189.6 |
| TABLE V - Extent of land mine injury. Values are numbers (percentages) of
victims* |
| Afghanistan
(n=1265) | Bosnia
(n=135)** | Cambodia
(n=443) | Mozambique
(n=176)** |
| No injury | 80(6) | 2(15) | 14(3) | 3(2) |
| Death | 699 (55) | 54 (40) | 139 (31) | 74 (42) |
| Loss
of: |
| Arm | 90 (7) | 24 (17) | 27 (6) | 18 (11) |
| Leg | 153 (12) | 34 (25) | 172 (39) | 47 (27) |
| Foot, toes, fingers | 142 (13) | 6 (4) | 97 (22) | 18 (10) |
Multiple fragments
in body | 109(8) | 12(9) | 94(21) | 4(8) |
| Blindness | 63 (5) | 3 (2.2) | 21(5) | 2 (1) |
| Head injury | 19 (1.5) |
| 23 (5) |
< D> |
| * Some victims had several injuries. |
| ** Details not available for all cases. |
| TABLE Vl - Details of surgery, admission, and costs of treatment in victims of
land mine accidents. Values are numbers (percentages) of subjects unless stated
otherwise |
| Afghanistan |
|
|
| Residents
(n=383) | Nomads
(n=107) | Bosnia
(n=99) | Cambodia
(n=304) | Mozambique
(n=174) |
| No of operations: |
| 0 | 14 (3.7) | 1 (1) | 58 (58) | 48 (16) | 100 (57) |
| 1 | 126 (33) | 30 (28) | 33 (33) | 165 (54) | 44 (25) |
| 2 | 119(31) | 44(41) | 34(34) | 66(22) | 12(7) |
| greater than or equal to 3 | 123(32) | 32(30) | 9(9) | 25(8) | 18(10) |
| Mean (SD) of no of operations | 2.3 (1.95) | 2.7 (2.9) | 1.1 (1.4) | 1.3 (1.1) | 0.93 (0.9) |
| Admission | 377 (98) | 104 (97) | 77 (77) |
| 88 (50) |
| Mean (SD) days in hospital | 120.4(131 /TD> | 114.8(146) | 55(86) |
| 67(102) |
| Costs:s |
| To pay | 381(99) | 104(97) | 21(21) | 223(73) | 43(25) |
| Had to sell goods to pay | 217(57) | 64(60) | 17(17) | 92(30) | 41(24) |
and injured 1.42; in Mozambique each blast killed an average of 1.45 people and
wounded 1.27. Roughly the same percentage of blasts (40%) was associated with
death in each country. Walking - to the fields and between or around villages -
was one of the highest risk activities in Mozambique, Cambodia, and
Afghanistan. Herding was the highest risk activity for Afghan nomads. In the
most recent fighting in Bosnia over half of the episodes were related to
military activity, mostly affecting soldiers on patrol duty.
Land mine incidents have increased sharply over the past 15 years, even when
the latest fighting in Bosnia is excluded. When the first four years of the
1990s were compared with the first four years of the 1980s, the incidence has
more than doubled. There were 195 cases in the Afghan, Cambodian, and
Mozambique samples from 1980 to 1983 and 610 from 1990 to 1993.
In Afghanistan one resident or nomad household in 20 tried to remove land mines
(304/6616); in Bosnia around 2% of households (20/1256); in Cambodia around 2%
(92/5996); and in Mozambique only 0 3% (28/9131) . A household in which members
had tried to move mines had four imes the risk of having a victim - usually
not the person who tampered with the mine (odds ratio 4 2 (3 6 to 5 6) Xsquared
= 189.6). The stratified risk difference, the proportion of cases that could
theoretically be avoided among households that tamper with mines, is around 19
4% (16.6% to 22.1%) (table IV).
DISABILITIES AND THEIR COSTS
The commonest injury among survivors of land mine incidents is loss of a leg,
as would be expected from antipersonnel devices (table V). Many victims had to
undergo multiple operations for their injuries (table VI). More than half of
all victims were admitted, each spending an average of two months in hospital.
In Cambodia 61% (184/302) of victims went into debt to pay for their medical
attention; in Afghanistan the proportions were 84% (317/376) among residents
and refugees and 87% (91/105) among nomads. Between 12% and 60% had to sell
assets to meet their medical bills.
Injuries affected victims' families and work (table VII). The commonest
complaint across the four countries was of reduced productivity. Family
relationships were affected for around one in every four victims; relationships
with colleagues were affected for about 45%.
FOCUS GROUPS
Clear messages emerged from some of the focus groups. In Afghanistan the groups
concluded that the most appropriate channels for increasing the awareness about
land mines were the radio, especially the BBC (22 groups); community meetings
(20 groups); schools (15 groups); and mosques (9 groups). In Cambodia community
meetings and interpersonal communication were identified as the best channels.
Ideas for employment opportunities among those disabled by land mines were
animal husbandry in Cambodia and workshops and artisan cooperatives in
Mozambique.
Discussion
War still continues in two of the countries we studied. While fieldwork was in
progress in Cambodia the Khmer Rouge launched a new offensive. In eastern
Bosnia one of our teams was imprisoned for three days while the community they
were surveying was "ethnically cleansed." Throughout Bosnia-Hercegovina there
was active fighting, sniper attacks, mortar bombings, and changing borders.
Under these conditions, information related to war casualties took on military
importance. As a result, some hospital staff, aid
| TABLE Vll - Social consequences of land mining accidents. Values are numbers
(percentages) of subjects |
| Afghanistan |
|
| Residents (n=383) | Nomads (n=107) | Bosnia (n=136) | Cambodia (n=304) | Mozambique
(n=174) |
| Main effect |
| None | 80 (21) | 35 (33) | 69 (51) | 28 (9) | 125 (72) |
| Reduced productivity | 118(31) | 24(22) | 25(18) | 193(63) | 17(10) |
| Mental health/dependency | 47 (12) | 28 (26) | 32 (24) | 47 (15) | 2 (1) |
| Health |
|
|
| 22 (7) | 18 (10) |
| Relationships with family |
| No effect | 182 (48) | 67 (63) | 103 (76) | 118
(39) | 153 (88) |
| Desertion |
|
| 5 (4) | 5 (2) | 4 (2) |
| Rejection cannot satisfy | 167(44) |
20(19) | 5(4) | 105(35) | 3(2) |
| Depression/dependent | 14 (4) | 3 (3) | 16
(12) | 64(21) | 9 (5) |
| Relationships with colleagues |
| No effect | 189 (49) | 66 (62) | 97 (71) | 97
(32) | 155 (89) |
| Loneliness | 36 (9) | 2 (2) | 12 (9) | 102 (34) | 10 (6) |
| Depressed/embarrassed | 83(22) | 11(10) | 20(15) | 76(25) | 3(2) |
| Improved |
|
| 5 (4) |
|
|
| Rejection/lost respect | 92 (24) | 8 (7) |
| 73 (24) | 4 (2) |
workers, and individual informants refused to participate.
Even allowing for possible overestimation by affected communities, this study
confirms a substantial toll in physical, mental, and economic disability
resulting from the widespread use of land mines. This cost falls to communities
already burdened by poverty and disease who, in economies fractured by war,
have to reconstruct their home lives and countries.
Programmes to increase awareness about mines are being widely undertaken in
affected communities.[xix, xx] Accurate recent local data about the number of
mine incidents and their risk factors can be an important contribution to and
focus for such programmes. In all four countries mines are sold as scrap metal
and in at least two of them freelance mine layers can be hired to put mines
near the home of a personal enemy. The fourfold excess risk of a mining
accident in households in which someone had tried to remove mines could form
the basis of an awareness programme. If no indirect association accounts for
this finding, stopping this practice could reduce a person's risk of injury
from mines to a quarter. This could make a compelling educational message.
But efforts to reduce the social costs of land mines can be, at best, a holding
strategy; they will soon be overtaken by the continued and increased deployment
of antipersonnel land mines. Only a total ban on the manufacture, export, and
use of these weapons can really help. Even if this happens, the World Health
Organisation estimates that at the present rate of clearance it will take 1100
years to remove all the existing land mines threatening thousands of
communities across the world.[ix]
Key messages
* Between 25% and 87% of households had daily activities affected by land mines
* One household in 20 reported a land mine victim, a third of them dying in the
blast; one in 10 of the 2100 victims was a child
* The incidence of land mine accidents has more than doubled between 1980-3 and 1990-3, excluding the recent
war in Bosnia
* Without mines, agricultural production could increase by88-200% in Afghanistan, 11% in Bosnia, 135% in Cambodia, and 3-6% nationally in
Mozambique
* A total of 54,554 animals were lost due to land mines, with a
minimum cash value of nearly $200 per household
* Households with a land mine victim were 40% more likely to have difficulty providing food for the family
* Family relationships were affected for one in every four victims
ClETinternational stands for Community Information and Epidemiological
Technologies; it is a non-profit non governmental organisation promoting
community based research. We recognise the generous contribution of the house
holders, key informants, and focus groups whose knowledge and suffering we have
tried to summarise in this paper. We also thank Barbara Reed, Charles Whitaker,
Alexandre Mondlane, Indira Kulenovic, Jose Legorrera, Julia Devin, Nicole
Massoud, Anne Cockcroft, Sareth Kloth and Hababullah, who coordinated fieldwork
and acted as coordinators for nearly 200 super-visors and interviewers. Reports
for the individual countries are available from NA.
Funding: United Nations
High Commission for Refugees United Nations Office for Coordination of
Humanitarian Assistance to Afghanistan, Unicef, Vietnam Veterans of America
Foundation, Open Society Institute, Halo Trust World Food Programme, Lutheran
World Services OXFAM, American Refugee Committee, Mine Awareness Group, World
Vision, Cambodian Mine Awareness and Clearance, International Committee of the
Red Cross Cambodia Trust, Organisation for Mine Clearance and Afghan
Rehabilitation, Food and Agriculture Organisation, Save the Children (USA),
Mine Clearing Planning Agency, Agriculture Survey of Afghanistan, Swedish
Committee for Afghanistan, and the National Planning Commission in Mozambique.
Conflict of interest: None.
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Cesar Palha da Sousa research associate
Sergio Paredes research fellow
Correspondence and requests for reprints to: Professor Andersson.