Book Review

Clearing the Fields: Solutions to the global land mines crisis

N Engl J Med 1995; 332:1525-1526June 1, 1995

Article

Clearing the Fields: Solutions to the global land mines crisis
Edited by Kevin M. Cahill. 237 pp. New York, Basic Books, 1995. $25. ISBN: 0-465-01177-2

Clearing the Fields: Solutions to the Global Land Mines Crisis is a comprehensive and authoritative book that presents the proceedings of a symposium held in New York on April 29, 1994, and cosponsored by the Council on Foreign Relations and the Center for International Health and Cooperation. The book reflects the experience of contributors from the fields of medicine, ethics, religion, human rights, humanitarian assistance, international law, public policy, and munitions. The contributors clearly present the scope of the international land-mine crisis and put forth practical suggestions for dealing with it.

There are more than 100 million antipersonnel land mines scattered across the fields, roads, and hillsides of some 60 countries. These mines cause an estimated 15,000 casualties annually, mostly among innocent civilians in developing countries. The mines not only injure and kill thousands of people but also inflict enormous social, economic, and emotional burdens on communities struggling to recover from armed conflicts. In the foreword to this book, the secretary-general of the United Nations, Boutros Boutros-Ghali, observes that the proliferation of land mines has created “a triple crisis: individual lives are shattered; families, communities, and societies bear an increasing medical burden; and states cannot proceed to develop lands and infrastructure rendered unusable by the presence of mines.”

Despite this grim reality, some 50 countries continue to manufacture and export 5 million to 10 million land mines a year. A number of the contributors to this book point out that mines are especially appealing to combatants in Third World conflicts because of their low cost, wide availability, and ease of use. Unlike many other weapons of war, land mines indiscriminately kill and maim innocent civilians long after a conflict has been resolved. As the editor of the book explains in his introduction, the removal of mines is a dangerous, costly, and time-consuming process, since most mines are placed without the use of maps or markers and consist of nonmetallic parts that escape easy detection.

The blunt trauma inflicted by land mines is graphically described in the chapter “The Medical Lessons of Land Mine Injuries.” The authors of this chapter, Chris Giannou, M.D., a surgeon with much experience in Cambodia and Somalia, and H. Jack Geiger, M.D., president of Physicians for Human Rights, present detailed information on the nature of injuries caused by land mines and discuss how these injuries are complicated by inadequacies of medical treatment, including shortages of x-ray film, antibiotics, and blood and medical staff who lack experience in treating blast-associated injuries. As the authors vividly describe, land-mine explosions not only tear tissue but also grossly contaminate wounds by driving soil, grass, metal, plastic, and clothing into the body. Foreign materials from a blast and bone fragments of a shattered foot are often blown into a patient's arms, buttocks, and abdomen. The percussion shock from an explosion can also destroy blood vessels far up in the leg, necessitating high amputations for foot injuries. As Drs. Giannou and Geiger describe, mine-blast victims often die of hemorrhage, tetanus, and gangrene. Long distances from treatment centers can delay treatment and exacerbate complications.

In “Developing Indigenous Amputee Programs: Lessons from Nicaragua and Somalia,” Drs. Cahill and Farah provide a detailed account of successful rehabilitative efforts in several countries. The authors emphasize that such efforts must be inexpensive, simple to teach and learn, easily standardized, and implemented by local personnel. They review the many successes achieved in several countries with the Jaipur foot, “a preformed, rubberized, durable, and flexible unit that requires little repair or replacement over a reasonable period of time.” Developed by the Jaipur Medical Center in India, this prosthesis is inexpensive and easily obtainable.

This book has several strengths. The editor has brought together an impressive group of distinguished contributors, including Cyrus Vance, former secretary of state, who represent specific areas of expertise and express various shades of opinion. This book does not merely seek solace in expressing outrage. Nor does it limit its aim to educating the American public about the dimensions of the land-mine crisis. Most of the chapters are frank discussions of how to solve the problem through the implementation of a wide range of realistic interventions. Some of these interventions, such as the United States ban on exporting land mines and the United Nations program for mine clearance, have already been implemented. However, others, directed at banning the production, stockpiling, transfer, and export of mines and their components, face considerable resistance from military establishments convinced of the continued necessity of land-mine use.

The medical, economic, and social problems created by land mines in such diverse areas of the world as Angola, Cambodia, and the former Yugoslavia are still not widely known in the United States. Clearing the Fields should help remedy this lack of awareness with graphic descriptions of the problems in their complex international setting. The book ends on a note of realistic optimism with the editor's conclusion that “hope rests on a worldwide movement, a slow, stumbling coalescence of determined private groups influencing governments and international organizations.” This hope, coupled with the bold and practical solutions put forth in this book, should help generate the international political will required to end this grim tragedy.

Pascal James Imperato, M.D., M.P.H.&T.M.
SUNY Health Science Center at Brooklyn, Brooklyn, NY 11203

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