Neurol Sci (2013) 34:2095–2100
DOI 10.1007/s10072-013-1343-7
ORIGINAL ARTICLE
Anatomical and neuropsychological effects of cluster munitions
Youssef Fares • Jawad Fares
Received: 14 October 2012 / Accepted: 20 February 2013 / Published online: 3 March 2013
Ó Springer-Verlag Italia 2013
Abstract The aim of this article is to investigate the
effects of cluster munitions on the different environmental,
anatomical and neuropsychological levels. We conducted a
study to explore the effects of sub-munitions on Lebanese
victims. The study included a total of 407 cases that have
been subjected to the detonation of unexploded sub-
munitions in Lebanon, between 2006 and 2011. In our
series, 356 casualties were injured and 51 were dead. 382
were males and 25 were females. We recorded 83 cases of
amputations, and injuries involving cranio-facial regions,
thorax, abdomen, and upper and lower extremities. These
injuries lead to loss of function, body disfiguration, and
chronic pain caused by the injuries or the amputations, as
well as post-traumatic stress disorder. The peripheral ner-
vous system was mostly affected and patients suffered from
significant psychosocial tribulations. Cluster munitions
harm human beings and decrease biodiversity. Survivors
suffer from physical and psychological impairments. Laws
should be passed and enforced to ban the use of these
detrimental weapons that have negative effects on eco-
system and societal levels.
Y. Fares and J. Fares are shared first authors.
Electronic supplementary material The online version of this
article (doi:10.1007/s10072-013-1343-7) contains supplementary
material, which is available to authorized users.
Y. Fares (&)
Neurosurgery Division, Faculty of Medical Sciences,
Lebanese University, Beirut, Lebanon
e-mail: yfares@ul.edu.lb
J. Fares
Faculty of Medicine, American University of Beirut,
Beirut, Lebanon
e-mail: jyf04@mail.aub.edu
Keywords Anatomical effects
Neuropsychological
effects
Post-traumatic stress disorder
Landmines

Cluster munitions
Cluster bombs
Introduction
A cluster munition is an explosive weapon that releases or
ejects smaller sub-munitions. Usually, it is used in an air-
dropped or ground-launched manner. The smaller sub-
munitions or bomblets are commonly designed to kill
enemy personnel or to destroy vehicles. In addition, some
incendiary cluster bombs are intended to start fires (Fig. 1).
Owing to the large number of bomblets released within
every cluster bomb, over a wide area, these bomblets tend
to pose threats to civilians during times of war. Even after a
war is over, unexploded bomblets remain capable of killing
and harming civilians for a long period of time. Methods
and techniques to locate them and remove them are still
costly and time-consuming.
Cluster sub-munitions tend to have different forms and
shapes that make it even harder for civilians to distinguish
them and identify them as threats. Therefore, more innocent
civilians, including children, will be victimized (Fig. 2).
Although typically not categorized as weapons of mass
destruction, munitions are believed, along with landmines,
to have killed more people than nuclear and chemical
weapons combined. They are responsible for killing ca.
800 people and disabling another ca. 1,200 people per
week [1].
Human Rights Watch has observed that ‘‘certain types
of cluster munition attacks tend to tip the scale toward
being disproportionate. Strikes in or near populated areas
are particularly problematic because when combatants and
civilians commingle, civilian casualties are difficult to
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Fig. 1 A cluster munition
containing hundreds of
sub-munitions dropped during
the 2006 Israeli War on
Lebanon
Fig. 2 An unexploded round shaped sub-munition that looks like a
ball, Lebanon, 2007
avoid’’. Hence, the Humans Right Watch considers that ‘‘a
cluster munition strike on a populated area should be
considered indiscriminate under the law’’ [2].
In 2006, Israel used cluster munitions on targets in
Southern Lebanon [3]. It dropped up to four million sub-
munitions on Lebanese soil, more than one million of
which remain unexploded ‘‘duds’’, according to the United
Nations Mine Action Service [4].
During and after 2006 War, Human Rights Watch said
that Israel had used cluster bombs very close to civilian
areas and described these bombs as being ‘‘unacceptably
inaccurate and unreliable weapons when used around civ-
ilians’’ [5]. The Watch concluded that these bombs should
never be used in populated areas.
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Neurol Sci (2013) 34:2095–2100
Table 1 Distribution of victims by age
Age Dead victims Injured victims Total
10–12 years 3 39 42
13–18 years 7 73 80
18–67 years 41 244 285
Total 51 356 407
We performed a prospective study regarding the envi-
ronmental, anatomical and neuro-psychological effects of
cluster bombs on the affected Lebanese individuals in
particular.
Methods
This study was conducted in the Neurosurgery Division at
the Lebanese University and its affiliated medical centers,
from September 2006 till August 2012.
We found out that pollution caused by cluster bombs
covered 42 % of the Southern Lebanese area; this lead to
the destruction of wide areas of agricultural landscapes.
Since 2006, a total of 407 cases have been prospectively
studied. 356 were injured and 51 were dead. 382 were
males, 25 were females. Ages ranged between 10 and
67 years. The age median was 27 (Table 1).
Injured patients underwent a neuro-radiological exami-
nation and were clinically evaluated. Post-traumatic
exploration was also done individually whereby each case
was studied on its own. From the injured patients: 29
suffered from head and facial lesions, 294 were affected in
lower body extremities, 221 had injuries in the upper
extremities, while 101 were affected in abdominal regions.
It should be taken into consideration that some of the
patients were affected in multiple regions in the body
(Table 2).
Neurol Sci (2013) 34:2095–2100
Table 2 Clinical manifestation and localization of the lesion in
victims due to cluster munitions
Injury type Children Adults
(10–18 years old) (18–67 years old)
Cranio-facial 8 21
Lower extremities 56 238
Upper extremities 32 198
Abdominal region 28 73
Out of the injured patients, 402 underwent surgeries and
were treated with anti-inflammatory and antibiotic medi-
cations and analgesics as appropriate.
Five of the 51 dead, passed away before reaching a
hospital. One of the five was a child picking grapes from a
grape vine: the sub-munition was settled on the grape vine,
he collected it unnoticeably and it detonated instantly. In
another case (out of the five dead), the sub-munition fell
down from an orange tree directly on an adolescent’s chest;
it exploded immediately.
Ethical approval was given from the Faculty of Medical
Sciences of the Lebanese University.
Results
The peripheral nervous system (PNS) was most frequently
affected. It was present in a total of 312 patients. 221
suffered from injuries in the upper extremities, 294 suf-
fered from injuries in the lower extremities, 159 had
injuries including both extremities (upper and lower).
29 of the patients, suffered from cranio-facial injuries.
Two of them had head injuries and seven of the rest suf-
fered from injuries targeting the facial nerve.
We detected 83 cases with member amputations: 27 in
the upper extremities and 56 in the lower ones. Most
amputees suffered from finger amputations.
The clinical results obtained before leaving the hospital,
recorded 301 cases with functional disability and 55 with
partial recovery.
The psycho-social effect was significant, whereby 312
patients were suffering from its consequences.
Discussion
Environmental effects
We consider cluster munitions to be one of the most
environmentally destructive aftermaths of war facing the
world today. Cluster munitions stand out from other forms
of warfare, because of their very persistent, undiscrimi-
nating and uncontrolled nature [6].
2097
Fear of the cluster munitions force populations to
move into subsidiary and fragile locations to avoid the
Total unexploded ordnances [7]. This migration speeds the
depletion of biological diversity since it disturbs essen-
tial soil and water processes, causing an acceleration of
29
ecosystem disruption and leading to land degradation
294
[8].
220
The contemporary definition of land degradation incor-
101
porates different natural and man-made phenomena that
result in the decay of human living conditions [9–11]. This
includes anthropological activities and war.
Cluster bombs can cause damage to the flora and fauna
at different ecological levels. Access denial, loss of bio-
diversity, soil disruption, chemical contamination, and loss
of productivity are several ways by which cluster bombs
can cause land degradation [6].
We consider that the use of cluster munitions guarantee
that people and their movements are channelled away from
strategically major spots. We believe that the fear from the
presence of even a single sub-munition can deny people
access to land that they dreadfully need for agriculture or
water supply (Fig. 3).
In our opinion, sub-munitions destroy vegetation cover
during explosions and when animals were victimized. This
way, plant and animal populations are threatened along
with those of humans.
We observed that soil disruption occurred when cluster
bombs explosions caused damage to the soils’ constancy
and deteriorated its structure. Troll [12] concluded that in
long-term changes, significant and sustained impacts on
moisture availability, erodibility and productivity of the
land will get impaired.
Soil contamination with heavy metals is observed in
areas surrounding the cluster bombs when the munitions
decay or explode. We recognized that 42 % of Southern
Lebanon i.e. 12 % of Lebanon’s total area was polluted and
contaminated with sub-munitions.
Therefore, due to land degradation, the productivity of
previously productive land decreased.
Anatomical effects
The individual with an injury due to cluster sub-munitions
may suffer initially any or all of the following: multiple
fragmentation wounds, amputation of one or more
extremities and loss of senses (vision, hearing, touch, etc.).
In our series, we recorded 83 cases of amputations, and
injuries involving cranio-facial regions, thorax, abdomen,
and upper and lower extremities (Fig. 4). These injuries
lead to: loss of function, body disfiguration, and chronic
pain caused by the injuries or the amputations, as well as
post-traumatic stress disorder (recurrent memories of the
injury and pain). These observations were also recognized
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Fig. 3 An unexploded sub-munition found unnoticeable in nature,
Lebanon, 2007
Fig. 4 A CT scan of the brain showing a craniofacial lesion that left
substantial sequels in the left eye of a Lebanese victim, 2006
by De Smet et al. [16], Doughterty [15], Somasundaram
and Renol [14] and Ascherio et al. [13].
Although cluster sub-munitions can inflict a variety of
injuries, Strada described and identified four general pat-
terns of landmine injuries: Patterns A, B, C, and D [17]
(Table 3). Another pattern for classifying landmine injuries
is also used: Pattern I correspond to Patterns A and B,
Pattern II correspond to Pattern D, and Pattern III corre-
sponds to Pattern C [18].
Often, after a detonation, we observed that vital struc-
tures are directly damaged causing extensive wounds to
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Neurol Sci (2013) 34:2095–2100
give a hemorrhagic shock. Thus, injured individuals are
typically in critical condition. Moreover, because explosion
of the sub-munition can propel dirt, grass, pieces of
clothing and metal fragments into the victim, wounds are
dirty and contaminated and cause a high risk of infection.
We propose a new classification method to identify and
describe injury scales for victims of cluster munitions. We
based our evaluation on the functional disabilities of the
victims. We used a scale based on the grade level (Table 4).
We observed that most of the injured patients were
evaluated to belong to grades I and II (Table 5).
Neuro-psychological effects
We agree with Patton that the effect of cluster munitions is
largely mental [19]. It is intuitively obvious that sub-
munitions induce fear. Because of its nature, some may say
that cluster munitions pose hazards very similar to land-
mines. However, there are differences in dealing with the
two. Primarily, because sub-munitions are usually on the
surface of the ground, rather than buried, they are signifi-
cantly easier to detect, often by simple visual inspection
alone. Furthermore, sub-munition casings are metal, which
also make them easier to detect with conventional detection
equipment. Hence, we can say that sub-munitions have
come to be an important fear-producing agent because we
can detect them by sight, i.e. we fear them because we see
them.
Affected individuals may suffer from a psychological
trauma. Many adults are unable to return to their jobs,
either having to retrain or remaining unemployed [20]. A
range of disorders are caused by the effects of cluster
bombs on the mindset of individuals.
In our series, we observed that fear was detected more in
children aged between 10 and 12 years of age and in adults
above 50 years old. Meanwhile, adolescents were negligi-
bly affected.
We agree with Gunaratnam et al. [21] that post-trau-
matic stress disorder (PTSD), acute stress reaction, anxiety
disorder and depression are found significantly in people
affected by sub-munitions. In our series, we found that
these disorders were mostly present within adolescents,
especially PTSD and acute stress reaction, knowing that
both disorders follow the exposure to extreme traumatic
stress as in war or disasters.
We observed that, initially, in the phase of denial there
was cognitive rejection of the stressful explosion-event. At
sometimes, most of our patients would show irritability and
aggression. This affected family life, friendship, work
relationships and interaction with support systems.
Phobia for stimuli or situations reminding the victim of
event is common. Some develop attacks of panic that last a
few minutes [22, 23].
Neurol Sci (2013) 34:2095–2100 2099

Table 3 Strada’s pattern of

Injury pattern Cause of the injury Anatomical effect
injuries due to landmine
explosions Pattern A Small blast munitions Amputation of the foot or leg
Pattern B Medium blast munitions Amputation of the leg; wounds to the: thigh, genitals,
buttocks, abdomen, chest and opposite leg
Pattern C Small blast of the munition Amputation of several fingers or one or both hands;
when hand-held injuries to the chest, face and eyes
Pattern D Large blast munitions Injuries throughout the body; instant death

Table 4 Fares’ Scale of injuries due to cluster munitions explosions

Grade level Percentage of functional disability Anatomical lesion

Grade I B25 Amputation of three fingers: middle finger, ring finger and little finger
Partial loss of a hand or foot
Superficial wounds to the body and face
Loss of skin and/or muscles in the extremities
Grade II 50 Amputation of two fingers: one of the two is the thumb
Loss of an eye, leg and/or hand
Wound infection
Recuperable lesion in abdomen and/or thorax
Psychological effects
Grade III 75 Affection of more than two of the four extremities
Partial loss of vision and/or impairment of the auditory system
Mutilation and partial loss of the digestive system and/or lungs
Lesion of the spinal cord
Grade IV [75 Amputation of three extremities
Total loss of vision and/or auditory capacity
Tetraplegia
Intellectual incapacity

Table 5 Distribution of victims according to Fares’ Scale formation of neuroma, central sensitization, cortical reor-
Grade level Number of cluster ganization, and pain memory [25].
munitions victims Most of the patients that were victims of cluster sub-
munitions suffered from various functional disabilities and
Grade I 175
incapacities. Stress, along with other psychological symp-
Grade II 203
toms, acted as non-supporting factors that increased the
Grade III 8
intensity of the disabilities and impaired the ability of the
Grade IV 21
patient to interact normally within the community.

Depressive illness is diagnosed if the mood lasts more

than 2 weeks. Depression is known to occur after trauma
[22] as well as a reaction to the loss of a limb due to a sub-
munition detonation.
We observed that the phantom limb feature struck
among amputees. When a limb is amputated, many severed
nerve endings are terminated at the residual limb [24].
Hence, this type of chronic pain is linked to alterations in
the PNS, the spinal cord, the brainstem, the thalamus, and
the cortex. Mechanisms that contribute to the elicitation
and perpetuation of chronic phantom limb pain may be the
Conclusion
The extensive use of cluster bombs by the Israeli army in
Lebanon is affecting the security of the Lebanese civilians
and it will continue to do so for many years to come. These
released sub-munitions are hugely destroying the Lebanese
environmental features and making it hard for tourism,
agriculture and other rural activities to continue and pros-
per. Cluster bombs and its undetonated ordnances are
subjecting Lebanese citizens to various anatomical and

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neuro-psychological effects that can be of a chronic nature
and affect multiple generations indefinitely. It is also
exerting pressure on the Lebanese government’s budget,
for the government is increasing its expenditures to remove
these munitions and to help in covering the medical-care
costs of the victims. The United Nations should stress on
laws that prohibit the use of cluster bombs at all times and
work on enforcing these laws at times of war or conflict.
The United Nations can also encourage countries to ban the
manufacturing of these bombs that affect innocent civilians
uncontrollably.
Conflict of interests None are declared.
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