Casualty Care Shifts as Situations Change           

In Kompong Speu, where the American Red Cross clinic makes and fits articial limbs and braces, just 40 percent of its patients are the victims of land mines. The rest are victims of diseases such as polio and cerebral palsy. In heavily mined Battambang, the International Committee of the Red Cross also makes artificial limbs for land mine victims. But it has recently begun making braces for polio and cerebral palsy sufferers too, and it expects the proportion of landmine patients to also drop to less than half the total patient load. These clinics are not alone in seeing the percentages of their land mines victims fall. "I think these figures can be transferred to other points in Cambodia," said Claude Tardif, the head of the AmCross clinic in Kompong Speu.

FIRST STEP: Physiotherapist Um Vanthin makes a mold of Hang Kansot’s arm.

Driving this change are two forces: the number of mine casualties, while still huge, dropped by half from 1996 to 1997 to 1,369 before leveling off this year, and the high-casualty black spots are becoming more localized. This is because military battles are closely linked to higher casualty rates, and lately fighting has tailed off.

"The conflict zones are more and more localized. That’s a good thing. The casualties will be less," said David Hunsberger, the manager of the Cambodian Red Cross database, which tracks mine casualties.

Seventy percent of casualties were in the four northwestern provinces in 1997, according to the CRC. Six provinces alone accounted for 92 percent. The trend has continued. Half the casualties are civilians, often refugees, usually poor, and who move onto vacant land as soon as the fighting end. Knowing that there are mines in the area but not exactly where they are, these people run the greatest risk of becoming victims.

"Contamination is not the issue," said Hunsberger. "Just because there are lots of mines doesn’t mean it’s going to produce lots of casualties." As land is cleared and as mine awareness programs reach villages, the casualties can drop too, he said.

At the AmCross clinic in Kompong Speu province physiotherapist Um Vanthin measures the stump of a man’s lower arm. He is working on Hang Kansot, a 21-year-old farmer who was brought in by the outreach team. When he was a boy, Hang stopped to play with a grenade which exploded and took off his lower arm. Now, the clinic will give Hang a plastic hand.

Um Vanthin, works quickly and efficiently to make a plaster cast. From this, the workshop will create a custom shell for the damaged arm and then fit a ready-made hand. Um Vanthin asks his patient to choose either a plastic hand or metal hook, and tells him to come back the next day for a first fitting. It all takes about 25 minutes.

NEW DIRECTION: Making braces at the ICRC workshop

Although less than half of the patients Um Vanthin sees are the victims of land-mine explosions, at one time they were the great majority, he said. "In the future, I think landmines are less and the traffic accidents are more," he said. The process of fitting a patient for an artificial limb is simple to do, but difficult to do right. The pressure must be applied to the least sensitive areas of the stump, and the prosthesis cannot pinch or rub. But if the fitting is good a person with an above-the-knee amputation can regain 65 percent of his freedom of motion and ability; below the knee fully 95 percent returns, said Joel Nininger, Chief Orthotist and Prosthetist at the International Committee of the Red Cross workshop in Battambang. He oversees the production of orthotics—braces—as well as prosthetics. "It’s a new thing here. The number of prostheses decreases because the mine victims decrease, but the center still keeps busy," said Nininger. He is enthusiastic about the quality of work done at the center. "Even for difficult stumps we are able to make very good quality [artificial limbs]," he said.

A prosthesis will last two or three years on average, though they are usually adjusted once a year. In Cambodia last year 6,317 prostheses were produced for new and existing patients, as well as 840 orthoses, in 16 rehabilitation centers. There are an estimated 30,000 to 40,000 amputees nationwide according to Amcross.

The biggest question mark remaining is the extent of the problem in the northeast of the country, where database coverage has been flimsy. Huge volumes of unexploded bombs and munitions are thought to lie in the dense forests of the northeast provinces, nearest to Laos and Vietnam, where the Americans pounded the Ho Chi Minh Trail from the air.

Observers for the Red Cross database made a rough survey of hospitals and local authorities in the area and were surprised by the results. "We think the incident level is...toward the low end of the scale," said Hunsberger. Reports showed no more than a couple of dozen incidents a year in each province, he said.

Spurred by lower casualties and a changing mix of patients, managers at the rehabilitation centers are shifting and improving their operations. This will be the first year that fighting has dropped enough for casualties to stabilize and the future to grow more clear. In the first nine months of this year, 973 people, were killed or injured, which is a slight decline from 1117 in the same period in 1997.

"After this year we will probably know what a baseline civilian rate will look like," said Hunsberger. According to the Mines Advisory Group, Cambodia has one of the world’s highest per capita casualty rates, and that is unlikely to change soon.

Story & Photos by Douglas Grindle