Revalidation of traumatic amputees in Cambodia

Jaap Tolk

 

Mysterious temple cities, traditional villages, the pristine Mekong Delta and fabulous powdery white beaches fronting crystal clear, turquoise blue waters. Nowadays Cambodia seems a tourist paradise, but underneath the soil lurks an ever-present danger. The Cambodian civil war and Khmer rouge rule have left the country with one of the greatest landmine burdens of the world. These eternal sentinels, as Cambodian soldiers and guerrillas called them, don’t recognize any cease-fire and continue to kill and maim hundreds of innocent civilians yearly.

 

A dangerous hidden heritage

Since 1979 more than 60 000 deaths and injuries from mines and other remnants of conflict were recorded, with 7 300 casualties in the last ten years. About 30% of mine victims dies and despite a large decrease from 875 deaths in 2005 to 243 in 2009, the landmine problem still represents a major impact on social and economic development of the country. With more than 25 000 amputees Cambodia has the highest percentage of inhabitants disabled by landmines in the world. The poorest of the poor, often children and grandchildren of the soldiers who laid them, are most at risk when forced by socioeconomic circumstances to work on mined land to make a living. According to the Cambodian Mine Victim Information System, 80% of the victims in 2004 admitted they were aware of the danger. In order to feed their families they were forced to have risky jobs such as collecting scrap metal and clearing dangerous areas for farming.

 

Delayed care for mine blast victims 

Due to their specific design to attack persons, damage inflicted by these brutal weapons is generally more serious than injuries caused by other conventional weapons. Early evacuation and prompt medical surgical care is crucial to save lives and reduce disabilities. Although for military personnel this kind of care is often available, for civilians in war-torn developing countries medical care within two hours of the trauma is practically impossible. Many mine blast victims often spent six to 24 hours from the moment of injury until they reach a hospital with surgical facilities. This delay in care can result in sepsis, shock and death. In Cambodia a low-cost pre-hospital trauma system, using outposts with locally trained staff for the first victim assistance, is being implemented around some hospitals in rural areas. The Landmine Monitor reported that in 2008 60% of new casualties received medical care within 30 minutes of their injury, reducing the fatality rate to 14% compared to 19% in 2005.

 

 

Walking with new legs 

Leaving the hospital as an amputee poses great challenges for gaining a livelihood. In rural Cambodia where muscle power is essential in agricultural work, amputees are often viewed as unproductive and simply another mouth to feed. Thus, proper prosthesis and rehabilitation is crucial. Currently, there are eleven rehabilitation centres throughout Cambodia, supported by a component factory in Phnom Phen. The component factory is the only source of prosthetic and orthotic devices in the country, supplying close to 15 000 patients a year. Local staff is trained to make inexpensive, durable limbs using simple polypropylene technology based on the International Committee of the Red Cross (ICRC) prosthetic limb. These prostheses consist of a socket where the remaining part of the limb is fitted, a pylon replacing the length of the limb (with a knee joint when amputated above the knee) and a foot. While Western devices cost about 10 000 dollars, the prostheses fabricated locally can be produced for about one percent of these costs and are much more durable to fit the demanding circumstances in which they are to be used. The prostheses typically last three to five years before they need replacement. A child with a lower limb amputation could be expected to need fifteen to twenty-five artificial limbs throughout life.

After the prosthetic limb is fitted, gait-training is needed for independence in mobility. Being able to walk without crutches is essential to be able to use your hand while moving. With a fitting prosthesis and after intensive revalidation, most people can achieve a reasonable level of activity and are able to work. In areas where disabled persons live far from physical rehabilitation centres, such as the highly mined areas near the north-western border with Thailand, the ICRC has mobile outreach programmes. Although progress has been made, the revalidation centres and most other projects are still not self-sustaining. Since government funds are lacking, external financing remains necessary.

 

An example for landmine struggling countries 

Clearly, prevention is the only way to cure this disease. Currently, the main preventive effort is the 1997 Mine Ban Treaty, which bans the production, stockpiling, transfer and use of antipersonnel mines. This treaty, in combination with almost twenty years of political stability, makes the landmine tragedy in Cambodia one with an optimistic long-term outlook. In many ways it can act as an example for countries still facing a huge landmine challenge, such as Afghanistan. In Cambodia, no new mines are being laid, the number of victims has dramatically decreased over the past years and the rehabilitation network is gradually improving. Still these horrible weapons will be influencing the Cambodian society for quite some time. The removal of the remaining mines is a painstakingly slow and dangerous job that will take decades, the need of care for the victims will last the rest of their lives.

About the author

Jaap Tolk is a sixth year medical student from Maastricht with a special interest in orthopaedic surgery.

 

 

Further reading

• www.icbl.org
• www.the-monitor.org
• Stover E et al. The public health effects of landmines: long term consequences for civilians. In:War and Public Health. ed.1996

 

Reference list

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