UXO? MM? QED

Abstract

Ahmed is an Arab boy, partially sighted, missing his right hand and whose left thumb is his best digit, even though it started life as a toe. He was walking home on a summer afternoon, saw a small high tech object gleaming in the sun, and reached for it. He regained consciousness in the back of a stranger's car and began the long and erratic journey to repair and reconstruction. Scarred and disabled, his injuries are typical of cluster bombs, or ‘sub-munitions’ as the military jargon goes. These devices, for the few readers who do not already know, are bombs that separate at a pre-ordained altitude into nearly 200 ‘bomblets’ whose diminutive name belies their ruthless capability. They are small explosive charges whose advantage lies in their ability to maim rather than to kill: a maimed soldier demands attention and takes at least one other out of the fight. Spreading over a wide area, the advantage of such munitions against scattered troops is easy to understand, and their effects can be devastating and as varied as their payload. But in built-up civilian areas their most relevant quality is that they cannot discriminate civilian from soldier, child from adult. Perhaps we should be glad that on impact up to 10% do not explode, but in fact they then effectively become small coke-can sized multicoloured anti-personnel mines. And guess which personnel are so naive as to pick them up? Children. In Afghanistan1Biukha O. Brennan M. Injuries and deaths caused by unexploded ordnance in Afghanistan: review of surveillance data, 1997–2002.BMJ. 2005; 330: 127-128Google Scholar, 2EditorialLandmines and cluster bombs–picking up the pieces.Lancet. 2002; 359: 273Google Scholar the lesson learned is that unexploded ordnance (UXO) poses a greater threat than landmines, and that children are the main victims of these brightly coloured sub-munitions so easily confused with similarly coloured food relief dropped from above (Fig. 1). By now some of you are getting nervous. Has the editor lost his mind: stay clear of editorials on political subjects, too dangerous. Too ambiguous. Too sensitive. Stick to plastic surgery. Oh, okay. Malignant melanoma. We all agree melanoma is not a good thing. It serves no purpose, kills almost randomly and our patients die unpleasant and premature deaths. So when we discovered that sunshine played a part in its genesis we had something to fight. We cannot outlaw sunshine (although they are not doing badly in Yorkshire) so let's make sure it is used safely. Cover up. Use sun blocks. Be safe. Care for your kids. Umm. Do you see where I'm going? Too simple? Maybe, but let's just remember that Iraq was a war of liberation. Western coalition forces are there to make things better, to improve life after Sadaam. Not to make Iraq a worse place for its people.3Roberts L. Lafta R. Garfield R. Khudari J. Burnham G. Mortality before and after the invasion of Iraq: cluster sample survey.Lancet. 2003; 364: 1857-1864Google Scholar, 4Horton R. Comment: the war in Iraq: civilian casualties, political responsibilities.Lancet. 2004; 364: 1831Google Scholar So, the rapid effective clean up of Western and Iraqi UXO should be conducted in Iraq as it would in those countries of the coalition, should not it? It must be unacceptable for children to be at risk firstly from the use of indiscriminate weapons in civilian areas, and secondly from any tardiness in cleaning up the UXO that litters these places. But what proportion of our munitions budget is devoted to clean-up? What small fraction? And then who treats these children. A lucky few have been funded by charities to get access to western reconstructive surgery. What about the rest? Iraqi medicine was excellent and will be again, but at present it is undeniably run down and unable to cope. So whose responsibilities are these children, and their wounded relatives? Surely some duty of care must attach to the coalition. In Britain, the government is making great strides in reducing waiting lists for elective surgery. What is it doing for the children whom its own sub munitions have damaged? Perhaps it feels the British public would resent the Health service being clogged with these cases. I doubt it: in the recent aftermath of the Indian Ocean tsunami the British public, like many others, has shown just how generous and caring it is, pre-empting its own government in its eagerness to help. Should the coalition have used cluster bombs in or near cities or civilians? Should there be an international strategy for treating the civilian casualties, of this war of liberation? Reconstructive surgeons, so plentiful and wealthy in the west and so sparse in Iraq, have a legitimate voice in these matters. We should express our opinions.