Stakeholders working within the framework of the Political Declaration, in collaboration with health actors in conflict, have a responsibility to ensure that all possible steps are taken to mitigate preventable death and impairment among civilian casualties from the use of explosive weapons in populated areas. This article synthesizes the direct effects of the use of explosive weapons in the form of death and injury among civilian populations, and highlights opportunities for enhanced coordination between health and protection stakeholders to address and mitigate this harm.
Introduction
Contemporary warfare in the 21st century has been characterized by the increased use of explosive weapons in populated areas, with significant impact on civilian populations. Whereas conflict-related casualties were historically predominantly male combatants, the effects of the use of explosive weapons in populated areas are indiscriminate, with an equal if not greater toll on women, children and the elderly.
Between 2011 and 2016 in Syria, for example, 75 percent of deaths among women and 29 percent of deaths among children were caused by the use of explosive weapons in populated areas, including shelling and aerial bombardments.1 Over this period, deaths among women quadrupled, and by 2016, approximately one quarter of casualties of explosive weapons used in populated areas were children.
These patterns of warfare are not unique to Syria, but rather are a feature of modern urban conflict. Based on casualty data from the war in Gaza since 7 October 2023, children are projected to represent an even greater proportion of trauma-related fatalities (34 percent), with nearly half (43 percent) among women.2 Though these data – derived largely from Ministry of Health registries – do not capture the quantitative proportion of deaths due to explosive weapons use, study investigators reported the majority of conflict-related trauma to be attributable to bombardments in densely populated areas. While the demographics of many resource-constrained countries affected by conflict are characterized by increased proportion of children and youth, these trends are nonetheless highly concerning for the toll of explosive weapons on civilians. These figures do not encompass the far-reaching indirect and reverberating effects of the use of explosive weapons in populated areas.
Blast injuries, including those caused by the use of explosive weapons, are a unique entity. Unlike penetrating trauma from gunshot wounds, blast mechanisms frequently inflict multidimensional injuries (i.e., concomitant mangled extremity/traumatic amputation, traumatic brain injury, thoracoabdominal trauma, and thermal injury or burns) with high injury severity scores.3 Such severe polytrauma can quickly overwhelm health systems weakened by conflict.
The Explosive Weapons Trauma Care Collective (ExTraCCt)’s systematic review of civilian casualties in 21st-century warfare identified vulnerable patient subpopulations with disproportionately high rates of death. In some cases, these rates were approximately four times higher than the overall cohort).4 These populations are predominantly child casualties of blast injury (specifically children under five years old and those with traumatic brain injuries), and patients with war-related burns.5 Each of these injury patterns is typical of those caused by the use of explosive weapons in populated areas.
Focusing on the direct effects of the use of explosive weapons in populated areas and the immediate consequences of blast injury, this article provides an overview of the potential for enhanced coordination between stakeholders to the ongoing process of work within the framework of the Political Declaration (including humanitarian mine action) and health actors to mitigate preventable death and impairment among civilian casualties.
The Political Declaration and casualty care
The Political Declaration on Strengthening the Protection of Civilians from the Humanitarian Consequences Arising from the Use of Explosive Weapons in Populated Areas, adopted by more than 80 countries in November 2022, refers specifically to the “blast and fragmentation effects” that “cause deaths and injuries, including lifelong disabilities,” (Section 1.3) and includes the commitment to “provide, facilitate, or support assistance to victims” (Section 4.5).6
The use of explosive weapons in populated areas in conflict settings causes significant death and injury among non-combatants.7 Though global estimates of explosive weapon-specific fatality rates are limited, estimates from casualty data of civilian victims of explosive ordnance demonstrate that at present, approximately 40 percent die of their injuries.8 This fatality rate is up to twenty times higher than that observed among blast-injured patients at military treatment facilities or high-resource civilian centers.9 This discrepancy in outcomes suggests that a substantial proportion of death among civilian victims of explosive ordnance and explosive weapons could be prevented with adequately resourced trauma care.
Though conflict and low-resource settings are by no means synonymous, certain challenges to accessing care are shared between environments. A systematic review of trauma systems development in low- and low-middle income countries found that approximately 80 percent of deaths in this context occur in the prehospital setting (for example, care provided prior to reaching a health facility).10 It is therefore reasonable to assume that a majority of preventable death among civilian casualties in resource-constrained conflict settings likewise occur in the prehospital environment.
Victim assistance in mine action has historically emphasized holistic, long-term rehabilitation (including, for example, physical, psychosocial and socioeconomic rehabilitation) in light of the complex and lifelong needs of victims.11 Yet if the majority of conflict-related deaths occur prior to reaching a health facility, under-explored potential exists to increase survival by expanding victim assistance frameworks closer to the point of injury. Numerous opportunities exist to collaborate with health actors to strengthen immediate post-injury care. However, to date these have not been fully explored in a structured manner.
Understanding civilian injury epidemiology in conflict
Attempts to increase survival from traumatic injury have historically focused on first understanding the causes of preventable death. Over the course of the wars in Iraq and Afghanistan, the United States military restructured its trauma care system to respond to the relatively high proportion of preventable prehospital death among military servicemembers, resulting in what ultimately came to be the Joint Trauma System (JTS).12 The military guided these changes by conducting continuous analysis of casualty data through the Joint Trauma Theater Registry (JTTR), thereby obtaining a clear picture of the causes of preventable death for those killed in action – most commonly extremity hemorrhage, followed by airway emergencies.13
Unfortunately, no such standardised registry or data source exists for humanitarian care in conflict. Available data fare frequently ad hoc with a lack of standardisation, rendering it challenging to draw clear conclusions about injury epidemiology among civilians in conflict, including casualties caused by the use of explosive weapons in populated areas.
Humanitarian trauma care differs from trauma care rendered to military casualties for many reasons. First, patients are not a homogenous population of healthy, predominantly male individuals ages 30-40. They encompass a demographic spectrum from children to the elderly, pregnant women and patients with pre-existing impairments.
Second, civilian casualty care occurs in the context of resource constraints that are dramatically different from those encountered by military personnel. Whereas military medical personnel have access to clearly established evacuation chains including air capabilities leading to the concept of the “Golden Hour” in trauma (for example, that immediate resuscitative trauma care provided within the first 60 minutes after injury are critical to survivability), in a civilian context prehospital transport may occur by any means available, including private vehicle, donkey, bicycle or foot.14 Casualty evacuation using these ad hoc means may take anywhere from multiple hours to multiple days. For example, one analysis of civilian conflict casualties in Kabul, Afghanistan, found that only 5.8 percent reached a health facility within the proverbial golden hour.15
Translating evidence-based practices from trauma care in low-resource settings to the care of casualties caused by the use of explosive weapons in populated areas
The challenges facing high-quality trauma care for civilian conflict casualties are significant, including the above-described gaps in casualty data, severe resource limitations and security constraints, including the deliberate targeting of and indiscriminate impact on humanitarian workers and health facilities.16
In the face of such challenges, what meaningful and concrete steps can be taken to improve outcomes among civilian casualties of the use of explosive weapons in populated areas and explosive ordnance in conflict settings? How can collaborative engagement between stakeholders be leveraged to increase the reach of such interventions?
With these two questions in mind, in 2022 ExTraCCt was established as a collaboration between researchers at the University of Washington’s Department of Surgery and the United Nations Mine Action Service (UNMAS). The initiative’s objective was to identify opportunities for enhanced coordination between humanitarian mine action and health actors in conflict with a shared goal of minimizing preventable death and impairment among civilian casualties of explosive weapons. Though originally identified within the context of mine action, the strategies identified represent concrete opportunities to operationalize the commitments of the Political Declaration.
Numerous interventions have been demonstrated to reduce trauma-related mortality in low-resource settings. Though adaptation is required for deployment in conflict settings, many have relevance to resource-constrained conflict environments. Workstreams to standardize and promote such interventions exist among multilateral actors like the World Health Organization (WHO) as well as local and national health stakeholders in conflict-affected countries (for example, national societies of the International Federation of the Red Cross and Red Crescent, Ministries of Health, medical student networks and civil society organizations).
Innovation not in technical guidance but rather in partnerships and implementation strategies is needed to ensure the most affected populations are reached. To provide structure to the dialogue around coordination between humanitarian mine action and health actors, ExTraCCt conducted multiple phases of background research to identify evidence-based trauma care interventions with demonstrated potential to reduce mortality in resource-constrained settings that held relevance for casualties of explosive violence.
Though many of these interventions may seem simple, such as trauma care trainings and standardised checklists for casualty resuscitation, numerous advances in care in high-resource settings have also been predicated on simple interventions. To provide only one example, layperson first responder trainings represent an underutilized way to bring lifesaving trauma care closer to the point of injury. This is analogous to the approach adopted by the United States military in its Tactical Combat Casualty Care or T-CCC, wherein all military personnel – not just those with medical backgrounds – were trained in immediate lifesaving aid. T-CCC has been widely adopted and attributed with a significant reduction in mortality among military servicemembers.17
In a context more relevant to civilian casualties, in the 1990s the Tromsø Mine Victim Center conducted layperson first responder and prehospital trainings in landmine-affected regions of Iraq and Cambodia.18 Over a five-year period, trauma-related mortality within the intervention area was reduced from approximately 40 to 15 percent. Though these trainings cannot supplant a full spectrum of trauma care and are only a means of increasing survival to reaching a trained provider, the full potential of these trainings are underexplored.
The WHO Community First Aid Responder (CFAR) training represents one layperson first responder training designed to be appropriate for resource-constrained environments.19 Integration with explosive ordnance risk education activities – such as one that will soon be piloted with Mines Advisory Group (MAG) among communities affected by improvised explosive devices (IEDs) in the Sahel – may significantly reduce preventable death.
Further opportunities are elaborated elsewhere as links in the Civilian Casualty Care Chain, or C-CCC (see Figure 1). Crosscutting all phases is the opportunity for improved casualty data collection and meaningful operationalisation of these data to enhance understanding of injury epidemiology to target interventions to the highest-risk populations, assess quality of care, benchmark impact of quality improvement initiatives, and to strengthen documentation of human rights violations.
Building off the United Nations Institute for Disarmament Research (UNIDIR) and Explosive Weapons Monitor workshop on Improving Data Collection Provisions of the EWIPA Political Declaration held February 29-March 1, 2024 in Geneva, significant potential exists for collaboration between stakeholders to the ongoing process of work within the framework of the Political Declaration and health stakeholders to harmonize casualty data and elucidate pathways for secure data sharing as a basis for policy and advocacy efforts.
Conclusion
Until the Political Declaration takes hold and injuries from explosive weapons can be more widely prevented, there is a shared responsibility to ensure all steps are taken to mitigate preventable civilian death and impairment among those affected. While high-level policy dialogues and implementation of the Declaration proceed, stakeholders in EWIPA and victim assistance in mine action, in collaboration with health actors in conflict, must take up this responsibility. The Explosive Weapons Trauma Care Collective seeks to engage stakeholders from both sectors to leverage novel cooperation to reduce harm related to the direct effects of EWIPA.