Elsevier

The Lancet

Volume 359, Issue 9320, 25 May 2002, Pages 1795-1800
The Lancet

Articles
Blunt and penetrating injuries caused by rubber bullets during the Israeli-Arab conflict in October, 2000: a retrospective study

https://doi.org/10.1016/S0140-6736(02)08708-1Get rights and content

Summary

Background

Low-velocity rubber bullets were used by Israeli police to control riots by Israeli-Arabs in early October, 2000. We aimed to establish the factors that contribute to severity of blunt and penetrating injuries caused by these missiles.

Methods

We analysed medical records of 595 casualties admitted. We assessed relation of severity of injury to type of bullet, anatomical region of injury, and final outcome. Severity of injury was established by the abbreviated injury scale, and we calculated injury severity score.

Findings

151 males and one female (age range 11–59 years) were included in the study, in whom 201 proven injuries by rubber bullets were detected. Injuries were distributed randomly over the body surface and were mostly located in the limbs (n=73), but those to the head, neck, and face (61), chest (39), back (16), and abdomen (12) were also frequently noted. 93 (61%) patients had blunt injuries and 59 (39%) penetrating ones. Severity of injury was dependent on ballistic features of the bullet, firing range, and anatomic site of impact. Two casualties died after a penetrating ocular injury into the brain and one died as a result of postoperative aspiration after a knee injury.

Interpretation

Resistance of the body surface at the site of impact (elastic limit) is the important factor that ascertains whether a blunt or penetrating injury is inflicted and its severity. Inaccuracy of rubber bullets and improper aiming and range of use resulted in severe injury and death in a substantial number of people. This ammunition should therefore not be considered a safe method of crowd control.

Introduction

Rubber bullets were used for the first time by British forces in Northern Ireland in 1970.1, 2, 3, 4 These missiles are intended to inflict superficial painful injuries, thereby deterring demonstrators from continuing further hostile activities, while at the same time avoiding serious injuries and deaths that arise with conventional firearms. The missiles are blunt-nosed, with a low muzzle velocity of 73 m/s and a muzzle kinetic energy of 402 J. The recommended safety range of these missiles is more than 40 m, but inaccuracy of the bullets makes it difficult or impossible to avoid hitting the face, head, and chest. Children and teenagers have been reported to have the most severe injuries from these bullets, particularly skull fractures and brain injuries, along with trunk injuries to the lungs, liver, and spleen.

To reduce the number of serious trunk and brain injuries inflicted by rubber bullets, more accurate plastic bullets composed of polyvinyl chloride, with a muzzle velocity of 71 m/s and a muzzle kinetic energy of 325 J, have been introduced.2, 4, 5 The enhanced accuracy and stability in flight of these bullets results in less frequent head and chest injuries than rubber bullets, but more severe skull and brain injuries, and often death.2

Between 1970 and 1975, over 55 000 rubber bullets were fired in Northern Ireland, with an estimated death rate of one in 18 000 rounds used, and serious injury rate of one in 1100 rounds.2 Plastic bullets were also used by the South African Security Force during the civil unrest in 1984, leading to a substantial number of severe facial injuries.6 During the Intifada between 1987 and 1993, the firing of rubber and plastic bullets by Israel Defence Forces resulted in several hundred significant injuries.7, 8, 9, 10 Although designed to avoid serious wounds and death, the firing of rubber and plastic bullets has resulted in a large number of extensive penetrating injuries and more than 20 deaths, mostly by injuries to the brain.10, 11

The Israeli Police Force also used rubber bullets to control demonstrations by Israeli-Arabs during early October, 2000. Police forces were instructed to fire the rubber bullets from a safe range of more than 40 m and to aim exclusively at the lower limbs of the demonstrators. We investigated casualties with injuries induced by rubber bullets, who were treated at a frontline clinic, two regional hospitals, and a level I trauma centre, to establish the factors associated with generation of blunt or penetrating injuries by a rubber bullet. We postulated that the major determining factor leading to blunt or penetrating injury by the rubber bullet, and its severity, was surface resistance to injury of the body area that was injured.

Section snippets

Study population

During riots by Israeli-Arabs in early October, 2000, several hundred people sustained injuries caused by conventional ammunition and rubber bullets. 13 people died as a result of those injuries. We analysed the medical records of 595 casualties who were admitted to a frontline clinic in Umm el Fahem, two regional hospitals in Nazareth, and the level I trauma centre at Rambam Medical Center in Haifa. We included in our study 152 casualties with proven injuries induced by rubber bullets.

Ballistic details

Rubber

Results

Of 152 patients with 201 proven rubber-bullet injuries, 35 were treated at the frontline clinic in Umm el Fahem, 101 were admitted to two regional hospitals in Nazareth, and 16 were referred to the Rambam Medical Center in Haifa. There were 151 males and one female, with an age range of 11–59 years (figure 1). 20 (13%) patients had more than one bullet injury, and in one (0·6%) individual, 13 bullet injuries were noted (figure 2).

The 201 rubber-bullet injuries were randomly distributed all over

Discussion

Both conventional ammunition and rubber bullets were used by the Israeli Police Force to control public disorders by Israeli-Arabs in early October, 2000. This use resulted in several hundred casualties and 13 deaths. 201 rubber-bullet injuries in 152 patients resulted in a substantial number of severe injuries and three deaths (2%), of which two were a direct result of injury and one was caused by postoperative aspiration after knee injury.

Our results show that the factors that most affect

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