Issue 4.2 | June 2000
Landmines are indiscriminate weapons, wounding and killing not only soldiers but women and children as well. Although hostilities may cease, landmines continue to maim and kill 500 victims a week, the equivalent of 26,000 additional disabled persons each year. There are at least 250,000 landmine-disabled people in the world, and the number continues to grow.
landmine issue will not end with the signing of a comprehensive treaty
on anti-personnel landmines. There are complex
in detecting and removing landmines, in preventing further injuries
and in assisting disabled persons and disrupted communities to reconstruct
their social, economic, political and civil infrastructures. Since landmines
and other unexploded ordnance have serious inter-sectoral consequences
for the reconstruction of war-torn societies, especially in developing
countries, they are best addressed from a development perspective, which
ensures due regard for the principles of equity, capacity building and
sustainability. These principles suggest that the landmine-injured and
war-wounded should not be segregated nor receive services which are
inaccessible to the general population of disabled persons. This could
be socially, and possibly politically, divisive.
Nicaragua has the most serious landmine problem in Central America. Since the war ended in 1989-90, there have been a series of demining programs and a national rehabilitation policy has been partially implemented.
Approximately 100,000 mines (out of an original 130,000) remain in Nicaragua. The principal areas of mine concentration focus on the Matagalpa area, which had intense fighting, and Chiandega, which had 106,000 square meters mined, especially near the Central American hydro-generating plant. Chiandega’s northern border of Honduras has 106 out of 206 kilometers still mined, and its southern border with Costa Rica has 16 out of 235 kilometers mined. The central area of Nicaragua (Esteli, Jinotega) has 318 mine sites, representing 206 square kilometers, and other areas of heavy mine concentration. Unexploded ordnance is also a major problem.
Deaths and Injuries
A reliable system for documenting landmine-related deaths and injuries does not exist in Nicaragua. Available information, which includes only those injuries that are reported to the police or to a prosthetic service, must be considered as rough estimates. Health post personnel in the rural areas are not required to report the cause of an injury. In some rural areas where there are no authorities (health, hospital and educational), people do not feel that they will be helped if injured, so they do not report incidents. The Nicaraguan military reports that from 1987 to 1997, the civilian population had 46 deaths and 470 disabilities from landmines while the military had seven deaths and 88 disabilities.
Overall, landmine injuries are fewer now than during the war (93 percent occurred prior to the peace settlement). However, more civilians and children have recently been injured. ICRC sources indicate that there are approximately 80 civilian mine incidents a year, mostly involving children, who are particularly susceptible to playing with landmines. For example, during the 1996 Christmas holiday, eight children were injured throughout the country in separate incidents.
Thirty percent of landmine injuries are severe, involving multiple body systems and long term disability while 70 percent require simple amputation or cause vision problems. In mine incidents, approximately 20 percent die and the rest survive with at least an amputation and often injuries to the face, eyes, ears, chest and genitals.
An Italian NGO, MOVIMONDO, has operated a program for six years and has direct contact with 7,000-8,000 war-injured persons, 15 percent of whom are prosthesis users. Their staff believes that there were at least 26,000 persons injured in the conflict. This estimate may be an under-approximation, as it may not take into account accidents that occur in remote areas.
NGO sources note that the overall magnitude of disability is very large in Nicaragua (approximately 12 percent of the 4.5 million population), but conflict has been only a part of the problem. For example, the principal cause of civilian amputations in 1997 was diabetes, but there are few reliable statistics.
Need for Action
The landmine problem in Nicaragua is severe, requiring action in demining, awareness, rehabilitation and reintegration. Although there is a formal government rehabilitation plan, it appears to be overwhelmed by the magnitude of need. A principal problem is that the national rehabilitation program has limited financial resources for health staff, for the recurrent costs of prostheses and for job placement programs. A second problem is a lack of rural community confidence in the government system and apprehension in accessing it. Finally, there is considerable dysfunction in the families of disabled ex-combatants due to altered social roles after years of fighting and disablement.
Facing these challenges, there is an existing network of NGOs and institutions which are already cooperating and providing a basis for programming. NGOs, with established programs in rural areas, could cooperate in community based rehabilitation (CBR) programs, which provide disability detection and referral as well as a practical transfer of functional skills to disabled people. This approach would improve access to basic rehabilitation services for the isolated, rural poor and provide an alternative where government services are limited.
Existing Ministry-supported health post personnel and brigadistas could also be recruited to provide basic rehabilitation services, building on the tradition of voluntary action. Multi-disciplinary teams could provide basic rehabilitation skills and training to health workers and volunteers, building up the CBR policy initiative of the government.
The supply of prostheses is adequate, although accessibility to this service in rural areas is hampered by the lack of a distribution system. Decentralization of the system from Managua to the regional level, using modular components as much as possible as well as mobile repair units, is possible.
A principal problem in Nicaragua concerns the affordability of prostheses. Agencies feel they are keeping up with demand, yet do not receive requests for prostheses because clients have become aware that they cannot afford them. Rural disabled persons are unaware of charitable financial support for purchasing prostheses. Private sector involvement, perhaps on a regional basis, could lower the costs of prostheses significantly. Specifically, the costs of prostheses could be lowered through increasing the number of modular components. For example, the foot section could be produced and distributed on a regional basis. This may improve the affordability for the average Nicaraguan, especially for families of child amputees. At the same time, increasing the ability of persons to pay for prostheses themselves, either through NGO savings or credit programs, is necessary. It is advisable to do estimates of lifetime costs for prostheses considering the need to replace them at least every five years.
Initiatives for economic reintegration of disabled persons are extremely difficult in the current economic context. Nonetheless, disabled persons should not face additional attitudinal barriers due to their impairment in finding employment. Integration is needed, but there is no national group with experience in doing this. Development of a local disabled people’s organization with skills in advocacy and public relations would be useful in this process. These groups could also develop local savings and loan programs for prostheses and micro-enterprises.
Mine awareness programs need to address the continued use of landmines for on-going conflict, revenge and land protection. Demonstration projects for isolated groups, such as the Organization of American States Program are excellently focused and targeted programs which provide service to the most needy. They serve a strategic purpose of demonstrating to both the bureaucracy and the rural population that something can be done. Finally, the International Committee of the Red Cross Child Landmine Awareness programs is a viable approach and should be replicated in these remote areas.
The presence of a national rehabilitation plan in Nicaragua indicates that disability has attained a certain priority in the country. The Nicaraguan Ministry of Health is currently working with PAHO on a disability information system. However, a multi-institutional (civilian, military, social security and private) and multi-sectoral approach (Health, Education, Labor and Defense) is required to implement the national rehabilitation plan for more effective coordination of non-governmental organizations, government funded institutions and disabled people organizations. Furthermore, policy refinement and key demonstrations of capacity in rehabilitation are required so that the Nicaraguan government has a solid consensus to proceed with rehabilitation development within the country.
The short-term emergency aspects of large-scale landmine and war injuries have decreased in the Central American region in this post-conflict period. Nonetheless, three significant long-term trends are particular to the context of war-related injuries. First, major traumatic musculo-skeletal injuries often require life-long rehabilitation input; amputation is an excellent example. Second, successful socio-economic reintegration of disabled persons, both combatants and civilians, requires both public acceptance and a healthy economic environment. Third, mental health problems in affected persons are often unrecognized needs which underlie the failures of rehabilitation at individual and community levels. These needs are complex and interactive in Central America, and they require a comprehensive development approach which does not privilege the war wounded above other disabled persons but which allows their urgent needs to be met.
Disability, because of its need for both personal change and social adaptation, demands a multi- disciplinary, multi-institutional and multi-sectoral approach. Management of disability problems requires interaction and negotiations between service agencies and can create opportunities to reestablish the basic philosophy of social service and economic reconstruction.
The Nicaraguan government is concerned about the needs of landmine-injured persons and recognizes the political impact of continual reminders of former conflicts. Government links to local community organizations and beneficiaries are partial with little penetration to rural areas, especially those on border regions where land mines are most pervasive.Government coordination of rehabilitation services varies considerably, even though Nicaragua has a formal rehabilitation plan. In practice, the implementation of rehabilitation services is lacking due to a scarcity of trained personnel, continuing economic restrictions and a clear geographic bias towards urban settings. Some ministries (Health, Social Security and Labor) are linked in order to address cross-sectoral concerns; however, the maintenance of four separate hospital and rehabilitation systems (general public, military, social security and private) wastes scarce resources. This duplication results in unequal access for those most in need. Nicaragua relies heavily on services provided by the NGO sector, yet, at the same time, separate private services are available for those with sufficient resources. There is some coordination across these systems, yet it is unfocused.
The quality and stability of rehabilitation personnel are adequate, even though the numbers are few. However, caution must be taken in training professional staff outside Nicaragua. Sufficient incentives and controls must be utilized so that trained rehabilitation staff return to practice. This requires the formal allocation of positions to rehabilitation in rural areas. Even with an increased number of trained staff, the demands on these personnel to be involved in planning and program development will escalate. Sufficient training in program planning, evaluation and policy development is also required to supplement their clinical skills.
The NGO sector has significant support from the public and has been only partially mobilized in the landmine survivor assistance issue. NGOs could be more fully integrated in areas of public education, primary health care, vocational training and public advocacy.
During post-conflict periods, the increased prevalence and visibility of physical injury from conflict is a constant reminder that peace is crucial, yet, at the same time it can engender resentment if needs are not met. The situation in Nicaragua creates an opportunity to heighten the profile of disability on the humanitarian development agenda. If action is taken to catalyze sufficient resources to address these needs, disability can become an issue common to divergent groups, which evokes a sense of common purpose and an openness to develop a strategic vision for community based peace building initiatives. Action on disability can provide both symbolic and tangible catharses to factions, to donor agencies and to civilian victims of conflict, which can diminish perceived barriers between disparate groups.
Regional Cooperation Issues
The countries in Central America differ greatly in their history of conflict, degree of medical rehabilitation, socio-economic infrastructure development and size and scope of conflict-related disability problems. There are, however, common conditions of physical security, economic under-development and social reintegration issues which can all be attributed to the landmine problem.
Opportunities for increased regional cooperation of Nicaragua in Central America should include considerations of economies of scale, non-duplication of technical services and optimizing the benefits of learning from each other’s experiences. Discussions have often focused on a regional approach to prosthetic services, and there has been considerable enthusiasm for this idea. There are different skill levels across regions and within countries, different institutional eligibility requirements for prostheses which affects affordability and can create potentially serious problems with regional communications and the timely transport of prosthesis sockets. Nonetheless, regional functions in prosthetic services could include elements such as prosthetic design, modular component production and service evaluation. Prosthesis assessment and measurement, production/ assembly, fitting/trials and repair should probably best continue as local functions. Other more likely areas of regional cooperation concern the development of CBR educational materials, public relation materials concerning economic reintegration of ex-combatants, mine awareness strategies for remote, isolated areas and micro-savings models.