Case presentation

The patient was wounded in a 1982 landmine accident in a Druze town in the Golan Heights, located metres from the 1967 Israeli–Syrian ceasefire line. He was 12 years old. Perched on a hilltop above the road on which he was playing with friends, a military outpost sat surrounded by a clearly demarcated minefield. Recent rains, however, had led to soil movement and washed a mine out of the field and onto the road itself. The blast injury resulted in loss of the patient's right leg above the knee, right arm above the elbow and right eye. After 20 days of sedation and another 3 months in hospital the patient returned home to an extended period of recovery and rehabilitation. He continues to receive financial aid from Israel's National Insurance Institute, though his application for additional recognition by the military was rejected.

One of his worst memories of the recovery period is his parent's home packed with relatives and neighbours who came to see him after his discharge from hospital. The patient recalls hearing the visitors lamenting his misfortune. He describes feeling as if they were taking pity on him. One conversation the patient remembers overhearing was between two elderly villagers discussing whether it would have been better for him to have been killed in the blast rather than to go through life as a ‘half man’.

The patient recalls finding support in his family's approach to misfortune as preordained. Their determination to channel energy towards moving forward, rather than frustration at present circumstances, was a motivating factor in the patient’s recovery. The patient believes this approach was rooted in his family's Druze religious faith. The patient frames his situation postaccident as a binary choice, to live or die. With what he describes as a loving and vibrant family around him, he recalls making a conscious decision to live because it was important for him to remain with them. Today, the patient sees obstacles in his path as new challenges to overcome. He views his rehabilitation as a series of projects to complete, rather than as a burden. With a smile he recounts how proud he was to be able to sit up in his hospital bed for the first time, a victory that brought tears to his eyes as he shouted for his brother to come see from the next room.

Physically unable to return to school at first, the patient continued his studies from home while also working on his physical rehabilitation. After completing his high school diploma in this way, the patient went on to earn a university degree and is now a financial professional. Active in the community, the patient makes regular appearances at local schools to cultivate the acceptance of disabled persons in society, and to promote landmine awareness and safety.

Recently, the patient married a woman from a nearby village. The patient describes the wedding as a turning point in the community's perception of him as a victim. Previous relationships did not result in marriage because of strong opposition by the women’s families. Their concerns were primarily domestic and economic—how would he be able to care and provide for a family? The patient describes his eventual success in finding a partner in marriage as a matter of meeting a woman strong-willed and independent enough to weather her family’s objections. Today he is married, and a father of two. Unable to accept prostheses as a child, the patient still prefers the aid of crutches, which he considers an extension of himself. He remains without prosthetic limbs by choice.

The next challenge the patient foresees is raising his young children, both in terms of their understanding of his condition and of his particular concerns for them. He notes that he never fully understood the emotional impact of his injuries on his parents. When his son broke a leg, the patient felt a powerful surge of emotion. The patient believes this experience brought him closer to comprehending the toll his accident had on his family. Indeed, he is clear that were his children to suffer an accident like his own, it would be a challenge he could not overcome.

Global health problem list

• Civilian morbidity and mortality due to explosive remnants of war.

• Lack of landmine awareness.

• Recovery and rehabilitation from traumatic injury with permanent disability.

Global health problem analysis

Along with Russia, China and the USA, Israel is one of 35 Ottawa Treaty non-signatory nations. Landmines persist as a public health concern in many regions of the world.1 Although official data are unavailable, experts estimate there are 260 000 landmines in Israel and the Golan Heights, primarily concentrated along the borders with Syria, Lebanon and Jordan.2 The Golan Heights is an area of particular concern due to a high concentration of Syrian and Israeli mines. According to local sources, more than 60 residents of the Golan Heights have been injured or killed by landmines since 1967.3 There are two clearly identified minefields on slopes surrounding former military outposts within the village discussed in this report.

Landmines have been associated with negative social and economic indicators in endemic zones around the world. Areas afflicted with landmines and explosive remnants of war show significant decreases in agricultural productivity and household economic viability. A study published in the BMJ found that households with a landmine victim were 40% more likely to have difficulty providing food for the family.4 Additionally, children account for a disproportionate share of landmine injuries.5

Community landmine awareness and safety education, as well as comprehensive mine removal, are crucial to preventing injuries like those described above.6 Towards this end, there has been recent cooperation between the Israeli Government and private groups to initiate education campaigns promoting awareness, especially during peak hiking seasons and among new immigrants.7 In addition, the psychological burden of landmine injuries must also be addressed. While this patient's case demonstrates resilience in the face of hardship, misunderstanding and stigma exacerbated the difficulties of rehabilitation. To improve recovery outcomes, community mental health counselling and support are a critical complement to life skills education and mine removal.8

Rehabilitation is key to postinjury response, but landmine removal is the cornerstone of prevention. The 2010 case of Daniel Yuval, a child who lost a leg in a landmine accident while hiking in the Golan, has brought increased public attention to the issue.9 In 2011, the Knesset unanimously passed legislation calling for the removal of landmines not imminently relevant to national security. Responsibility for the clearance effort is shared by the Department of Defence and private contractors. This work will be overseen by the Defence Ministry's Mine Clearing Authority. Landmine removal efforts are to be funded jointly by the Israeli government and humanitarian organisations.10 ,11 This work has begun and included clearing one of the two minefields within the Druze town discussed in this report. While progress has been made, the Israeli Defence Ministry's Mine Clearing Authority estimates that at the current rate of removal the completion of the project will take 50–60 years due to financial constraints.12 Funding for removal efforts in the Golan and areas confronting similar burdens is essential to the prevention of morbidity and mortality due to landmines and explosive remnants of war. The dangers of this work must also be noted. Highlighting these risks, in May 2013 an Israeli Corps of Engineers soldier was killed by a mine while clearing a field in the southern Golan Heights.13