At one point in history, a soldier in combat would have been injured with a bow and arrow. That bow and arrow eventually became a bullet, and in the 1890s, that bullet evolved into the ‘dum-dum bullet,’ designed to expand on impact and inflict severe injury. Because of its potential to gravely wound combatants, The Hague Convention of 1899 prohibited the use of the dum-dum bullet in international warfare.
A century later, landmines, designed to maim and injure, rather than kill, were deemed indiscriminate weapons with potential to inflict serious injury. After a high-profile campaign waged by a coalition of non-governmental organizations, 162 countries signed the 1997 Ottawa Treaty pledging to stop their production and use.
Today, a far more dangerous weapon in use on the battlefield – the improvised explosive device or IED – needs to join the ranks of prohibited weapons, according to an international research team led by Schulich School of Medicine & Dentistry Surgery professors Shane Smith and Vivian McAlister. The group’s study of the weapon and its impact – Injury profile suffered by targets of antipersonnel improvised explosive devices: prospective cohort study – was published last month in the journal BMJ Open.
“The IED is worse than the dum-dum bullet by one-hundred-fold. More than 100 years ago, people said it was not right to try and injure combatants to the extent of using dum-dum bullets. And today, we are accepting, every day, these dreadful IED injuries. We need to say this is not right and we have got to stop,” said McAlister, a Canadian Forces surgeon.
IEDs have replaced landmines in modern warfare. While they are often portrayed as primitive and crude weapons, they have evolved and are sophisticated, directed and destructive, according to researchers.
The mechanism of injury is the same for landmines and IEDs, while the seriousness of injury depends on how close the victim is to the centre of the explosion. McAlister and his colleagues eliminated bystanders from their study cohort to specifically look at injuries sustained by those in the weapon’s proximity. They assessed injuries sustained by 100 people during IED attacks in Afghanistan over 18 months between 2010-11 and compared them with injuries previously described for landmines.
“What we found is the worst set of injuries ever recorded in a cohort of patients – that’s how bad it is. It’s terrible, and the outlook for the world is appalling if they allow this to go on,” McAlister noted.
The study’s results are “horrific,” he said.
IED victims were more likely than those similarly injured by landmines to have more than one amputation – 70 per cent of IED victims had more than one amputation, compared to 10.5 per cent of landmine victims. Five out of the 70 multiple amputees had four amputations; 27 had three amputations, and 38 had a double amputation. Among nine children and teens, three had a triple amputation and five had a double amputation.
IED victims were also twice as likely to sustain genital/gluteal (buttocks) injuries and pelvic fracture was more common among IED victims who had multiple amputations and/or genital/gluteal injuries when compared to landmine victims with similar injuries. IED victims with this pattern of injuries were also nearly four times as likely to die than were similarly injured landmine victims.
The casualties, comprised of civilians and military personnel, were all male, between 6-44 years of age. The average age was 25 and nine were under the age of 18. Eleven victims were dead on arrival. Eight subsequently died of their wounds in hospital, giving a fatality rate of one in five, or 19 per cent.
In all, the typical injury profile of IED victims included amputations of both legs (often above the knee); mangling or amputation of an arm/hand; extensive soft tissue injuries with deep penetration of soil, extending into the gluteal and perineal areas; pelvic fracture; and genital mutilation.
“This is appalling. It’s not acceptable and I’m afraid there are groups throughout the world who are supporting individuals doing this, who think this is acceptable. And society is going to have to say it’s not acceptable,” McAlister said.
“We’re only medical personnel – our hands are completely tied. Our first priority is looking after soldiers and looking after the victims of war. We could go through that patient cohort and come up with strategies to help these patients survive – and we have come up with important strategies. But in the end, I think this is why I’m making a plea about this. This is a weapon that is beyond all human norms and decency and it’s got to stop. Society has got to be abhorred by this.”
The injuries documented by McAlister and his colleagues are “superfluous,” causing unnecessary suffering and harm, he noted. And a subtlety that must be noted following this study is the fact that such injuries meet the medical criteria for war crimes in international law. While such a classification needs to meet other conditions, the medical results are nevertheless horrendous and the injuries sustained by soldiers on our behalf will require lifelong support, McAlister added.
“In the end, people have to say it’s just not acceptable.”