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'War surgery is ICRC's flagship medical assistance program for people affected by conflicts'

by Sarath Malalasekera

The second seminar on War Surgery was held on June 14 and 15, at the Galadari Hotel Colombo.

The keynote of the Seminar was "War Surgery in Time of Peace."

War Surgery is the flagship program of the International Committee of the Red Cross' (ICRC) Medical Assistance to people affected by conflicts. The ICRC endeavours to improve management and treatment of war wounded by offering assistance in materials and equipment when necessary, training as needed and the dispatch of ICRC surgical teams in extreme cases. With experience gathered over the past 139 years in conflict zones around the world, the ICRC's specialists have expertise and experiences they can share with fellow Medical specialists working in these regions.

Dr. Jean Pierre Revel, Assistance Coordinator, ICRC, Colombo delivering the keynote address said that "War Surgery in time of peace' sounds not only provocative, but also is an incredible paradox since it includes in less than a sentence two words which are usually mutually exclusive, namely; 'war' and 'peace.' As everyone knows when there is way, there is no peace and peace usually means that war is over, regardless, or because, of this paradoxical title, we thought that this could be an excellent invitation to initiate or rather to stimulate the debate."

"You might wonder why a "non-surgeon" like me has accepted to deliver this address. I would have a two fold reply- first by a kind of joke. Quoting a French politician of the beginning of the last century who, in the middle of World War I said. "War is too serious an issue to leave it exclusively to military," I could say that "Surgery, and even more war surgery, is too serious an issue to leave it exclusively to the surgeons." Second, in a more serious way, I am deeply convinced of the tremendous power of cross fertilisation between disciplines and I am sure that this seminar will be a brilliant example of what can be achieved when various professionals meet and genuinely accept share their ideas and experiences," Dr. Revel said.

The Chief Guest was Dr. M.A.L.R. Perera, Secretary, Ministry of Health, Nutrition and Welfare. The Guest of Honour was Major General L.C.R. Goonewardena, Chief of Staff of the Sri Lanka Army. Other speakers at the inauguration included Isabelle Barras, head of delegation of the ICRC in Sri Lanka

Major General Dudley Perera, Medical Advisor Sri Lanka Army, Dr. Chris Giannou, head of the Surgical Unit, ICRC Geneva and Dr. N. Ganeshananthan, President, College of Surgeons Sri Lanka also spoke at the seminar. The first War Surgery seminar was held in Sri Lanka in June 2001. 171 specialists attended it, the organisers of the seminar said.

Dr. Jean Pierre Revel in his address said:

"Contrary to its precedent edition, this second "Seminar on War Surgery" is taking place at a unique period of time in the recent Sri Lanka history. The hostilities are kept on hold by the Memorandum of Understanding and the talks currently going on, and these may hopefully lead to a solution to the conflict that has been affecting the whole population for many years. In line with this tremendous change likely to occur, we as surgeons, doctors or any health professionals, need to adapt to the coming new environment. We need to look forward to the future but it would be foolish to forget the lessons from the past. This is exactly what we intend to do during this seminar, reviewing some of the major issues of a discipline that has established its credibility through development and adjustment of techniques learnt from the battlefields, and so for centuries.

Dr. Reved said: Among these circumstances, the stress due to the widening gap between the needs on the one hand and the resources on the other hand, a traditional ratio in public health, is of paramount importance. In the needs to be addressed one will find the following:

Traditionally: large number of patients to be attended, within a short period of time. Even if they are less and less frequent, battlefields used to provoke large number of casualties, most of them at the risk of dying if they were not properly attended on short notice. Nowadays, evolution goes in two main directions. On the one hand the number of casualties may be less important, but the complexity of the wounds, the variety of the causes and the severity of the condition of those admitted, have significantly increased requiring an even more sophisticated approach. On the other hand, many war wounded world-wide have no access to even basic health care since infrastructures and services are ruined by the conflict in which they were involved.

Second, Most of the times casualties brought to the advanced medical posts present heavy physical damage, due to explosions, blasts and burns. These result in state of shock and their condition will deteriorate quickly if they do not receive adequate first-aid and pre-hospital care. In order to be effective in the management of these cases one would need special techniques from triage to identification and classification of the wounds, and proper stabilisation of the patients' condition. If tremendous progress has been achieved in this regard during the last fifty years world-wide, it is largely due to lessons drawn during conflicts and beyond, in mass casualty incidents.

These are extreme cases illustrating the long term effects of such weapons, both result in the death of the victims. In most cases, shells and artillery rounds kill, their shrapnel wound and main as do antipersonnel mines. Antipersonnel mines have witnessed an incredible success world-wide as an of issue for community mobilisation during the 90's. Campaigns developed in all countries during the 90's to achieve the ban on this type of weapon culminated in the signature of the Ottawa Treaty and the attribution of the Nobel Peace Prize. Information released during these campaigns highlighted the primary objective of such devices: not to kill but to inflict injuries as severe as possible. These will affect the individual, of course, but also his/her family and the community at large and will hamper their development.

Classically, victims of antipersonnel mines are women and children, non combatants and therefore protected as such by International Humanitarian Law. Unfortunately, antipersonnel mines, UXO, are threat common to quite a lot of places in Sri Lanka. Looking at some statistics for the preparation of this address, I noticed that in Jaffna area, over the last two years, the vast majority of victims were men. How can this be explained? One hypothesis may be that year 2001 was still a period of active hostilities and women and children were kept away. In 2002, following the cease-fires, men were wounded whilst exploring the places where they used to live before taking the decision to resettle. Another hypothesis is that the time span for such statistics is too short and as time will go by we may see more women and children affected. As they will be increasingly resuming their normal or traditional activities ... Looking also at the causes of these accidents, we can see that several devices are involved in these, but of paramount importance is the land mines which account for more than 60% of all these cases. In other places of the world, the same trends may be noticed. Whether it is Afghanistan, Kosovo or Bosnia & Herzegovina after the cessation of hostilities, APM are causing the highest level of death or injury in the civilian populations.

Even though careful demining associated with mine awareness programmes are carried out and repeated for years and years, one can imagine that accidents will continue to occur since they do occur right now. We cannot exclude that children, adults, elderly will be killed or maimed by these devices. In such cases, we have to know what to do and to do it in the most appropriate way so as to save as much chances as possible for the victims to carry out a decent life after their accident. This is where the know-how and the links with other disciplines are so important.

As surgeons, you are on the front-line "AFTER" the accident has occurred. Victims' lives will never be normal anymore. However, we can make a significant difference and alleviate much of their suffering. Together with pre-hospital care, resuscitation and rehabilitation teams, you bear the responsibility for the future of these victims. It is of utmost importance to know how best to amputate the limb so as to provide the best chances to fit a prosthesis and prevent recurrent pains. This has been a lesson taken from thousands and thousands of amputations carried out all over the world by ICRC Surgeons during the last twenty to thirty years. And one of the most striking lessons is that surgical procedures must go along with physical rehabilitation. This is why we have included a presentation on physiotherapy and prostheses at the end of this seminar.

Even though the hostilities have stopped, all over the places affected by the conflict, thousands, maybe hundreds of thousands of these deadly weapons are still waiting to go off, hampering for long the return to "normal life" in these areas. On already vulnerable communities, the socio-economical burden of these weapons is beyond our understanding.

It is therefore critical to pursue as much as possible the objective of a total ban of these weapons and to stop their utilisation in all conflict situations. This is the raison d'etre of another important ICRC activity: the organisation of seminars aiming at discussing ways, countries could use to achieve the total ban on anti personnel mines. In this regard, I feel it highly significant that such a regional seminar took place here in Colombo, in August 1999, gathering representatives of six countries from South Asia, namely: Bangl-adesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka. This clearly demonstrates the wide range of activities to be implemented in this area to link prevention and response", he said.

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