Pediatrics, War, and Children

Article Outline

• Armed Conflict and Pediatrics
• Report of a Symposium of the Program for Global Pediatric Research: “The Effect of Armed Conflict on the Health and Development of Infants and Children”
• “Public Health and the Human Cost of War”
• “Infant and Child Health During and After Armed Conflict”
• “Excess Childhood Deaths Resulting From War in Northern Uganda”
• “Impact of Armed Conflict on Infant Mental Health and Early Development”
• “Psychological Research on the Impact of Armed Conflict in Children: The Need for a Holistic Approach”
• “Abuse of Children During and After Armed Conflict”
• “The Professionalization of Humanitarian Assistance and Its Implications for Child Health”
• Conclusions
• A Review of the Literature
  • Conflicts and Children: Direct Impact of Weapons and Breakdown of Child Protection Systems
    • Direct Human Cost of Warfare
    • Breakdown of Child Health and Protection Systems
  • Impact of Conflict on Children's Development and Psychological Well Being
  • Especially Vulnerable Groups
    • Refugees, Internally Displaced Persons, and Orphans
  • Child Soldiers
    • Girls
    • Children With Disabilities
  • Strategies to Support Children Affected by Conflict
• Conclusions
• References
• Copyright

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Armed Conflict and Pediatrics 

Armed conflict, unfortunately, has been a fact of life for centuries and undoubtedly will continue to be so in the future. However, the nature of conflict is changing, and this is leading to dire consequences for children. Before World War II, combatants incurred the majority of injuries and deaths. During the Second World War, millions of noncombatants, including women and children, were killed. Previously, most wars were between countries; today, most armed conflicts occur within countries. Indeed, the “use of violence against civilians in times of war was one of the last century's most alarming military developments.”¹ This troubling trend continues to this day, and the effect on children is devastating. During the past 25 years, millions of children lost their lives, were disabled, and left destitute and homeless by war and conflict.

Yet, the study of the health and long-term development of children in war zones has not been a major priority of pediatric researchers or of our professional societies.

Does pediatrics have a role to play in researching the effects of conflict on children's health, in devising short-term and long-term interventions, and advocating for the rights of children during and after armed conflict? We believe it does. In May 2008, during the annual meeting of Pediatric Academic Societies in Honolulu, Hawaii, the Programme for Global Paediatric Research (PGPR)¹ held a symposium entitled “The Effect of Armed Conflict on the Health and Development of Infants and Children.” The symposium brought together pediatricians and researchers, along with representatives from United Nations Children's Fund (UNICEF), Save the Children, International Rescue Committee, the Harvard Humanitarian Initiative, and others devoted to the problems of children in developing countries, and especially those in zones of armed conflict. A workshop was held the day after the symposium to hear additional presentations and to discuss topics that were raised in the symposium. We were asked by the editors of Current Problems in Pediatric and Adolescent Health to present a report of that unique meeting. That report constitutes the first part of this article. The second part provides a comprehensive review of the world literature dealing with the effect of armed conflict on children's health. These efforts are attempts to bring these issues to the attention of pediatric clinicians and researchers, and to determine how pediatrics may contribute its knowledge and experience to the solution of this major problem of global child health.

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Report of a Symposium of the Program for Global Pediatric Research: “The Effect of Armed Conflict on the Health and Development of Infants and Children” 

–Held at the annual meeting of the Pediatric Academic Societies, Honolulu, HI, May 5, 2008

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“Public Health and the Human Cost of War” 

–Frederick Burkle, Harvard Humanitarian Iniative, USA

Dr. Burkle provided evidence of the early and late impact of conflict on child disease and survival. He pointed out that conflict adversely affects the public health system and its protective infrastructure related to water, sanitation, shelter, food, and health. Hence, the protective threshold is destroyed, overwhelmed, not recovered. or maintained, or denied. As a result, most child illness, injury, and death occur in the months and years after the conflict has ceased (ie, “after the shooting stops”). This is shown figuratively in Fig 1. Dr. Burkle referred to direct and indirect effects of armed conflict. Direct effects include injury, death, human rights abuses, and psychological stress. Indirect effects include mortality and morbidity resulting from population displacement, destroyed infrastructure, lack of food, and medical care. As a result, child illness and death is at its greatest after the war when the entire supportive structure for child health has been reduced or destroyed. Dr. Burkle pointed out that the failure of the health system is also related to its status before conflict. Those poor countries with a very poor health system before the conflict have the worst health system after conflict.

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• FIG 1. 

  A figurative diagram illustrating the percentage of deaths due to conflict (“direct”) and “indirect” in the period “after the shooting stops.” (Reprinted with permission.) (Color version of figure is available online.)

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“Infant and Child Health During and After Armed Conflict” 

–Renee van den Weerdt, of UNICEF

Dr. van den Weerdt spoke about “Infant and child health during and after conflict.” She first presented a graph showing under-5 mortality globally (Fig 2). Although this information is an overall picture of worldwide mortality in 2007, the mortality after armed conflict is due to these same causes. Toole and Waldman² pointed out that the mortality and morbidity that occurs during and after armed conflict is the same as in these populations before war but the incidence is much greater. Countries with the highest under-age 5 mortality rates in peace time are also those that have suffered greatly from armed conflict. Dr. van der Weerdt emphasized and outlined the many factors affecting populations during and after armed conflict, (Table 1). All these factors demand not only medical expertise but also the input of social and legal expertise as well as local and international government and humanitarian support. The magnitude of deaths occurring during armed conflict is emphasized by comparing deaths during all natural disasters to those which occurred during the Congo war (Fig 3). Clearly the order of death and undoubtedly suffering was huge especially when compared with disasters that capture the world's attention. Although there are many specific causes of deaths in this population many of the deaths reported, for example, under dysentery, diarrhea, and enteric fevers are in fact, starvation deaths. Malnutrition is wide spread in low-income countries and is evident in the aftermath of war. The reasons are many. Certainly, a lack of food is central; however, there are other compelling reasons, including breakdown of family units, disruption of communities, and social support, and the many direct and indirect effects of armed conflict listed in Table 1. One study reported by Toole and Malkki³ showed a relationship between undernutrition in a community and mortality rate. In their study of 42 refugee populations they examined crude mortality rates (CMRs) and acute protein malnutrition prevalence (PEM). Analysis of the data showed a strong positive association between PEM prevalence and CMRs. Populations with a PEM prevalence rate of less than 5% had a mean CMR of 0.9/1000/mo. Refugee populations with PEM prevalence of greater or equal to 40% experienced a mean CMR of 37/1000/mo! The rate ratio between the lowest and highest CMR values was 40.7. Malnutrition is a major underlying cause of child mortality in low income countries and undoubtedly this is a major problem in the aftermath of war (Fig 4). Dr. Van der Weerdt concluded by stating with reference to child health during armed conflict: progress made, the challenges ahead and the opportunities that await (TABLE 2, TABLE 3, TABLE 4).

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• FIG 2. 

  WHO World Health Statistics, 2007. (Color version of figure is available online.)

TABLE 1. Characteristics of populations affected by armed conflict

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• FIG 3. 

  Deaths due to armed conflict (war in the Congo) compared with deaths due to natural disasters (floods, earthquakes, etc). (Color version of figure is available online.)

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• FIG 4. 

  Malnutrition underlies child mortality in the aftermath of armed conflict. (Color version of figure is available online.)

TABLE 2. Progress made in the health of children affected by armed conflict

TABLE 3. Gaps and opportunities in the health of children affected by armed conflict

TABLE 4. Opportunities in improvement of child health for children affected by armed conflict

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“Excess Childhood Deaths Resulting From War in Northern Uganda” 

–Jane Aceng, Makere University, and Margaret Nakakeeto, Mulago Hospital, Uganda

Neonatal deaths are a major component of the high child mortality rate in low-income countries and in the aftermath of armed conflict. However, detailed on-site studies of childhood mortality after armed conflict are difficult. This matter was studied recently by Drs. Jane Aceng and Margaret Nakakeeto. They carried out an important study of neonatal and childhood mortality resulting from war in Northern Uganda. In parts of Northern Uganda, the last 20 years have been characterized by uninterrupted conflict due to the insurgency of a rebel group, the Lord's Resistance Army, against central government authorities. Up to 2 million people −90% of the population—were forced to live in camps as internally displaced persons (IDPs). Each camp held 40,000-60,000 people and some of them have been in existence for a decade. As is often the case, there were no accurate data on child health and mortality in these camps. Drs. Aceng and Nakakeeto undertook to estimate CMR and the under-5 mortality rate (U5MR) in the period from January 2005 to July 2005 among populations living in IDP camps. The study included causes of deaths and related demographic information. They compared their findings to the CMR and U5MR expected in their region which was approximately 0.44 per 10,000 persons per day, and 1.14 per 10,000 under 5 persons per day, respectively. IDP camps in 4 regions within the Acholi district of Uganda were studied. In each camp, 30 clusters were selected, each with 32 homes. Interviews were carried out in 960 homes in each of the 4 districts. The CMR for the Acholi region was 1.54−approximately 4 times higher than CMR for the region outside the camps. The U5MR was 3.18 per 10,000 under 5 persons per day or greater than twice as high as the expected rate (1.14). Most deaths were due to those diseases seen in low-income countries (diarrhea, pulmonary infections, and malaria) as discussed earlier. Neonatal mortality during that time was studied. In the 1394 households surveyed, 412 pregnancies were reported. There were 367 live births, of which 132 died because of various causes: 51 of 132 (38.7%) who were followed up died in the first month of life; 63 of 132 (47.8%) died at home (in the camps). Major symptoms among the dead included failure to breastfeed and difficulty in breathing. The overall neonatal mortality rate was 140 per 1000 live births (4 times the national average of 33/1000 live births). This remarkable study emphasized not only the risk to children in the aftermath of war but the very high risk to neonates during that time.

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“Impact of Armed Conflict on Infant Mental Health and Early Development” 

–Raija-Leena Punamaki, University of Tampere, Finland

Dr. Punamaki presented the study, “Impact of armed conflict on infant mental health and early development, the intrapartum period and during early infancy and childhood.” Dr. Punamaki summarized the effect of trauma on children from early infancy to adolescence. She described developmental steps, the tasks expected at each stage of development, and the effects of trauma at each stage. She then reviewed the evidence that maternal health and response to stress can affect the fetus in utero and the life of the child borne thereafter.⁴, ⁵ Evidence suggests that the trauma of war on pregnant women may affect the physical and emotional health of children.⁶ The response of children to the violence of conflict will depend on the developmental stage of the child as well as the degree of trauma. The role played by a supportive family is critical. In studies of aggressiveness in children following or witnessing violence, supportive parenting was important in ameliorating aggressiveness. Dr. Punamaki reviewed the effects of trauma and the response in terms of individual resilience of the children and the support of the family. She concluded:

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“Psychological Research on the Impact of Armed Conflict in Children: The Need for a Holistic Approach” 

–Ed Cairns, University of Ulster, Northern Ireland

Dr. Cairns first emphasized the importance of this issue by citing the increased violence on civilians in zones of armed conflict. During World War I, 19% of casualties were civilian; during World War II, 48% of the casualties were civilians. During the 1980s and 1990s, 80% of casualties were civilians. Dr. Cairns reviewed the studies related to the effect of violence on children and found that many lacked critical design, analysis, and an appreciation of the background literature. He then discussed the issue of “resilience” in children exposed to trauma. It was once thought that children were relatively resistant to the effects of trauma, but this concept has fallen in and out of favor. However, it is now recognized that the response to trauma of children is clearly influenced by many factors, including the child's own emotional stability as well as the response of family and society. Given the many factors affecting the response to trauma, Dr. Cairns and colleagues have undertaken a critical analysis of the effect of the previous conflict in Northern Ireland on the mental and emotional health of children. He concluded by citing the need for future studies of this selected population.

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“Abuse of Children During and After Armed Conflict” 

–Harendra De Silva, University of Kelaniya, Sri Lanka

Professor Harendra De Silva, University of Kelaniya, Sri Lanka, spoke about “Abuse of children during and after armed conflict,” with particular reference to the recruitment of boys and girls to serve in groups involved in armed conflict. Children have been used to fight wars for centuries. This was seen in Germany and in Russia during the Second World War and recently in Sri Lanka. Children have not only been abducted to serve as soldiers and provide support for the armed forces; many have also “volunteered.” Professor De Silva reviewed the reasons for volunteering, including hatred of the enemy, deaths of family members, becoming a freedom fighter, and supporting the family. All of this has been intensified in many communities by the glorification of fighters, their cause, and their martyrs. Professor De Silva describes conscription of children to serve with armed forces as a form of child abuse: “The involvement of dependent, developmentally immature children and adolescents in armed conflict they do not truly comprehend, to which they are unable to give informed consent, and which adversely affects the child's right to unhindered growth and identity as a child.” He concluded by saying that children are prone to abuse in many ways during armed conflict. Conscription of children in armed conflict, for whatever reasons, constitutes child abuse and should not be considered as heroism or martyrdom. The prevailing impunity during war—especially civil war—perpetuates abuse of children like many other crimes. There is need for international recognition that conscription and inclusion of children in armed forces is a form of child abuse.

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“The Professionalization of Humanitarian Assistance and Its Implications for Child Health” 

–Ronald Waldman, Mailman School of Public Health, at Columbia University, USA

The need for organization is clear when one considers the problems faced by a population during and after armed conflict (Table 1)—all of which affect child health. The need for organization and professionalization is great, and that has only started to occur recently. Dr. Ronald Waldman, of the Mailman School of Public Health at Columbia University, USA, reviewed the development of professionalization and made it very clear that there is a need for organized services in support of children in zones of armed conflict. The history of this is most interesting. For some time there was no organized form of professional support for those families. A major change occurred during the Biafra war in Nigeria. A group of physicians became incensed about their inability to provide assistance to those in need because of the neutrality of the International Committee of the Red Cross and they founded “Medicins Sans Frontiers” (Doctors Without Borders); one of the co-founders was Dr. Bernard Kouchner, the current foreign minister of France. That led to increased medical services in zones of conflict; however, actual planning for the needs of these communities only began with the efforts of the US Center for Disease Control during the Cambodian genocide with studies of camps in Thailand. In that initiative, assessment of health status and application of preventive medicine of Kampuchean refugees produced tremendous improvement in health within the camps. Similarly, in Somalia, in 1979, the US Center for Disease Control again brought public health initiatives to the conflict with amazing results. Out of it grew “EPICENTRE.”

Epicentre is a nonprofit organization created in 1987 by Médecins sans Frontières, which includes groups of health professionals specializing in public health and epidemiology. It brings epidemiologic science to areas of public health that are difficult to practice. In 1996, Epicentre became a World Health Organization (WHO) Collaborating Center for Research in Epidemiology and Response to Emerging Diseases.

Subsequently during the Rwandan genocide a group of lawyers were concerned about standards for humanitarian assistance and especially about the protection of human rights of people affected by disasters. This led to the development of the Sphere project. It set minimum standards in core areas for humanitarian assistance. The aim of the Sphere project is to improve the quality of assistance provided to people affected by disasters, and to enhance the accountability of the humanitarian system in disaster response. It is clear that to solve the many problems of children affected by war there is need for organized input, to bring the expertise and concern of medical, legal, social, and political groups to bear on these problems.

The following presentations preceded the workshop, held on May 6, 2008, following the symposium:

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Conclusions 

The effect of armed conflict on children is devastating. It includes death, disability, emotional trauma, and long-term developmental failure. Many pediatricians have played an important role in the care and study of children in developing countries during the aftermath of armed conflict. But clearly there is more to be done: to bring these issues to the attention of the world community, to do further research that can lead to better interventions, to provide medical attention to children in conflict zones, and to advocate for the immediate and longer-term health needs of children in conflict zones who may have no advocates. These issues benefit from the knowledge of pediatrics, not only in the provision of services or the focus of research, but also in the traditional role of pediatrics in advocating for the health needs of all children.

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A Review of the Literature 

By the end of the 20th Century, approximately 1.8 billion people were living in countries that were either at risk of, affected by, or recovering from conflicts.⁷ In 2003, the World Bank reported that 80% of the world's poorest countries had recently experienced major conflicts.⁸ Poverty and conflict are closely associated. Given the high rates of child mortality and morbidity in some of the world's poorest countries, it is not surprising that at the time of conflict the vulnerability of young children increases when family, community, health, and education systems weaken further. UNICEF reported that of the 10 countries with the highest rates of under-fives mortality, 7 were affected by conflict.⁹

The impact of war on children is devastating. Two million children were killed and a further 6 million were seriously injured in armed conflicts from 1986 to 1996.¹⁰ Many more children were exposed to food deprivation, spread of infectious diseases, psychological harm, disability, separation from family, loss of education, displacement, abuse, abduction, torture, and slavery.¹¹ The short- and long-term consequences of exposure to war and violence require a range of different interventions.

The purpose of this review is to present an overview of the evidence of the impact of conflict on children and key strategies for intervention followed by the important role the child health community can play in global advocacy, intervention and research.

Conflicts and Children: Direct Impact of Weapons and Breakdown of Child Protection Systems 

It is widely recognized that children bear the major brunt of displacement after conflict and war. Children are exposed to direct threats to their survival by the armed conflict. Much has been written about the arms trade (legal and illegal) and cost to civilian life. Southall and O'Hare¹¹ reported that small arms and light weapons are responsible for the majority of conflict casualties, mostly women and children, and in 2001 were implicated in more than 1000 deaths per day.

In addition to small arms and light weapons, land mines probably pose the most insidious and persistent danger to children in conflict zones.

Despite public outcry and recognition of their destructive potential to civilian populations, land mines continue to be used in most conflicts globally. It is recognized that land mines and unexploded ordnance pose a particular danger for children.¹⁰ Children are also more vulnerable to the danger of land mines than adults because they may not recognize or be able to read warning signs. Children are naturally inquisitive, more likely to pick up strange objects they come across, and are also less likely than adults to recognize the tell-tale signs of land mines and impending danger. In a deplorable example of targeting children, the Soviet Union littered rural Afghanistan with brightly colored land mines shaped like toys and “butterflies.” The risk to children is further compounded by the way in which mines and unexploded ordnance become a part of daily life. Children may become so familiar with mines that they forget they are lethal weapons.

Child soldiers are particularly vulnerable to land mine injuries, as they are often the very personnel used to explore known minefields. In Cambodia, a survey of mine victims in military hospitals revealed that as many as 43% had been recruited as young soldiers between the ages of 10 and 16. In Afghanistan, it is estimated that almost a third of all land mine victims were children.¹² The victims of mines and unexploded ordnance are also inordinately greater among the poorest sectors of society because of the risks people face in their daily life. In conflict zones, especially rural populations, these tasks may consist of cultivating their fields, herding animals, or searching for firewood. In many cultures, these are the very tasks carried out by children. Although antipersonnel mines are designed to maim and not to kill, they can be potentially fatal for children. Although in Cambodia almost a quarter of all children injured by mines and unexploded ordnance die from their injuries, the risk of mortality with land mine accidents in Afghanistan was almost 55%.¹³ In a comparative evaluation of land mine accidents in 4 areas of conflict including Afghanistan, Bosnia and Herzegovina, Cambodia, and Mozambique,¹³ the highest population-based rates of land mine accidents were seen in Afghanistan.

Among those who survive land mine injuries, the consequent medical problems and rehabilitation needs are also much greater for children, as the limb of a growing child grows faster than the surrounding tissue and may require repeated surgery. As they grow, children also need expensive new prostheses and regular care. Land mine injuries are a frequent direct cause of medical impoverishment with 57%-60% of all families involved having had to sell household goods and property to pay for treatment. It is estimated that there are still close to 10-15 million unexploded mines in Afghanistan.¹⁴

The immediate and long-term costs of land mine injuries are also compounded by the high costs of clean-up operations and land reclamation. It is recognized that clearing land mines can be both long and extremely expensive. To illustrate, clearing each land mine takes 100 times longer to remove than to deploy. Thus, a weapon that costs $3 or less to manufacture may eventually cost $1000 to remove, limiting the resources available for essential services.

In addition to the direct threat of harm from weapons, during conflict and postconflict recovery phases the disruption of family, community, health, education, law, and social welfare systems expose children to multiple risks to survival and well being. This disruption can be the result of the warfare or in the case of Iraq; the international sanctions which resulted in an increase of under-fives mortality from 56 to 131 per 1000 live births in the period of 1994-99.¹⁵

Seeking access to healthcare for treatment may be disrupted because of unsafe travel and curfews, breakdown in medical supply chains, and the diversion of services to meet the needs of combatants.⁹ For children, the breakdown of health services during conflict has particularly dangerous implications not only in terms of receiving curative treatment, but also because of the disruption of rural vaccination programs. During Bangladesh's struggle for independence in 1971-1972, childhood deaths increased by 47%. Smallpox, a disease that had virtually disappeared before the conflict, claimed 18,000 lives. By 1973, in Uganda, immunization coverage had reached an all-time high of 73%. After the fighting started in that country, coverage declined steadily until, according to WHO sources, by 1990, fewer than 10% of eligible children were being immunized with antituberculosis vaccine, and fewer than 5% against diphtheria, pertussis, and tetanus, measles, and poliomyelitis.

Young children are also exposed to greater risks of malnutrition. The availability of food is disrupted. Farmers are not able to grow and harvest their crops efficiently, and problems may be compounded by economical disarray in a country at the time of conflict. In addition to the distribution of food, young children's nutritional well being will be affected by the family environment. Mothers who are themselves malnourished or experiencing high levels of distress may not be able to feed and care for their children effectively. Increased prevalence of malnutrition is thereby likely to increase the chances of infection. Since 1990, the most commonly reported causes of death among refugees and IDPs during the early influx phase have been diarrheal diseases, acute respiratory infections, measles, and other infectious diseases such as tuberculosis.¹⁶ Even in peacetime, these are the major killers of children, accounting for some seven million child deaths each year.¹⁷ These data are corroborated by the impact of conflict on childhood malnutrition in Ethiopia,¹⁸ Congo,¹⁹ and even relatively well developed parts of Eastern Europe.²⁰

Children can demonstrate a remarkable resilience, even in times of great disadvantage. The support structure of families and communities, including schools, need to be protected so that positive social support for children can be provided.²¹ In the districts of Swat and Dir in the North-West Frontier Province of Pakistan, in the last year alone militants have destroyed 172 schools (70% of these schools were girls' schools).⁹ Children and adolescents have been deprived of education and a social support system that is essential for their future.

Children are harmed directly by warfare and also by the accompanying breakdown of systems. In addition to urgent issues of meeting safety, health and nutrition needs of children, their recovery in the short- and long-term is dependent on addressing the rebuilding of social, cultural, economic, and legal infrastructures.²⁰

Impact of Conflict on Children's Development and Psychological Well Being 

In the previous section, the impact of conflict on the physical health of children was described. In addition to being a direct cause of child mortality, increased morbidity, and susceptibility to malnutrition are observed in conflict affected populations. The risk factors which result in high rates of disease and malnutrition are also likely to have a detrimental impact on child development.²² Failure of child development is a major problem, especially in low-income countries. It is estimated that 200 million children under 5 years of age fail to reach their full cognitive potential.²³, ²⁴

Cognitive, language, and social-emotional development is likely to be affected in a context where the care giving environment of the child is disrupted. Research on child development highlights several significant psychosocial risk factors which will impair development: (1) Inadequate stimulation (opportunities where the child can learn about the world around them through safe exploration, imitation of adults, and practice of new skills); (2) Maternal depression which impedes the mother's level of sensitivity and responsiveness toward her child and; (3) Violence.²², ²⁵ Many children are exposed to these parenting and contextual risk factors in conflict affected areas. Studies on preschoolchildren exposed to community violence or armed conflict from South Africa and Israel report higher levels of post-traumatic stress, behavioral problems, and depression.²⁶, ²⁷, ²⁸

It is clear that the physical and emotional effects of armed conflict lead to deaths and disabilities and thereby constitute major global health problems. An additional problem, indeed a major problem, is the effect of wars on child development—both cognitive and social. The first 3 years of childhood are critical for normal child development; however, most studies documenting the effects of direct exposure to armed conflict involve children older than 5 years. As a result, there is little information available on the effect of war on child development. More research is necessary to examine the consequences of conflict on child development in children less than 5 years of age.

Indeed, it is likely that a major impact of war is the failure of child development. It has been pointed out that the impact of developmental failure leads to poor education, inadequate contribution to the economy of a country, further poverty, and, as adults and parents, to the intergenerational transmission of poverty. All those causes also occur during and in the aftermath of armed conflict. Thus, in addition to disease, failure of normal child development is a major problem in the period after armed conflict when all normal support systems have broken down.

Much has been written about psychological trauma in children affected by conflict. The lasting impact of war on the psychological state of women and children are well described.²⁹ These effects may consist of post-traumatic stress disorders (PTSD) suffered because of witnessing or experiencing parental loss in war,³⁰ whereas in others political repression³¹ and state terror have been shown to result in significant psychological sequelae. More recently a study of internally displaced children from the war in Bosnia and Herzegovina has revealed features of PTSD in 94% of cases,¹ and it has also been demonstrated that the negative effects of war may overwhelm coping mechanisms.³² The same phenomenon has been observed in Kuwaiti children who lived through the Gulf war and in Kosovo.³³, ³⁴ More worryingly some reports suggest that children and adolescents scarred by war transmit their problems into the next generation in a quasi-genetic fashion.³⁵, ³⁶

Sri Lanka has been affected by civil war for more than 2 decades. Conflict in the North-Eastern provinces has killed, maimed, and displaced many thousands of the civilian population. A recent study sought to investigate the association of traumatic experiences and school performance among a sample of 420 children. Only 8% of those surveyed reported no traumatic experiences (including witnessing or experiencing bombing, shelling, attacks on the home, death of family members, sexual abuse). Of those who had reported trauma, 25% met the criteria for PTSD. The experience of trauma was significantly associated with poor scores in school achievement tests and memory tests, and the scores were even lower for those meeting the criteria for PTSD.³⁷

A meta-analysis has been performed on all studies on the prevalence of mental disorders of children exposed to war reported up to 2007. Studies were published from 1986 to 2005.³⁸ A total of 17 studies were found involving 7920 children (ages: 5-17 years). Four of the studies were done during conflict and the others were a follow-up 1 month to 5 years after conflict. All studies measured PTSD as a primary outcome. A meta-analysis showed a range of 4.5%-89.3% with an overall rate of 47%. It is evident therefore that children are exposed to major emotional traumatic events and suffer emotionally immediately and for long periods thereafter.³⁸ More systematic research on the trauma and PTSD experienced among preschool and school age children affected by war is required to understand the actual prevalence and implications on daily functioning and the development of appropriate strategies.

Summerfield²¹ cautions the danger of labeling entire generations of young people affected by conflict with trauma or psychological dysfunction, which may misguide appropriate rehabilitation interventions. Child development experts recognize protective factors in the child's caregiving environment and experiences, the age and development stage of the child, family and social support, and the nature of the trauma that affect an individual's resilience and response to trauma. The variation in response to trauma can be categorized into 3 broad categories: (1) nature of the trauma, (2) gender and personal characteristics of the traumatized individual, and (3) social, cultural and political context of the conflict affect population.

Baker and Shalhoub-Kevorkian³⁹ explored responses to trauma in Palestine. They reported that Palestinian children and adolescents exposed to extreme forms of traumatic events were more likely to have symptoms of PTSD. The Palestinian experience, from both peer-reviewed and non–peer-reviewed literature, consistently shows that girls are more likely to suffer significantly more symptoms of anxiety, depression, and PTSD. This may be a result of differential gender roles and expectations in Palestinian Society. Irrespective of gender, children and adolescents with high levels of self-esteem and internal locus of control displayed better coping strategies in response to traumatic experiences. Finally, Palestinian culture is placed on the collective and not the individual, therefore; social support by the community is perceived as a protective factor by many children and adolescents.

The negative psychological effects of exposure to violence are likely to increase when family and community structures are broken and the mental health of care givers is disrupted, and will be influenced by the nature and number of traumatic events observed. However, studies from Bosnia and Herzegovina, Eritrea and Sierra Leone have shown investments in educational interventions among conflict affect children can help improve children's psychosocial functioning.⁴⁰, ⁴¹, ⁴² Therefore, while mental health specialists may provide important help in selected cases in post conflict areas, for many more children educational and social systems must be considered priorities in supporting their health and well being.²¹, ⁴³

Especially Vulnerable Groups 

Although all children are vulnerable in conflict affected areas, some children may be especially at risk. Wars have several other worse effects on children including loss of parents and other close relatives, many leave their education because of poverty, displacements, disabilities, and the destroyed infrastructure of schools. Many street children have no shelter and are dependent on relatives for a place to stay and are otherwise vulnerable to abuse.

Many refugees from armed conflicts have fled to disadvantaged countries that cannot afford to care for them, whereas wealthier nations are inclined to block their entry.²¹ Conditions in camps, such as overcrowding and poor hygiene, are often conducive to large-scale outbreaks of disease. For example; in 1985, a severe measles epidemic in the Wad Kowli refugee camp in Sudan resulted in 2000 deaths of under-fives in a 4-month period.⁴⁴ A similar scenario was observed almost a decade later in Goma where more than 85% of mortality among the Rwandan refugees was associated with diarrheal disease transmitted by rapid fecal contamination of Lake Kivu, which was the primary source of drinking water for the population.⁴⁴ The prevalence of malaria among refugees from Afghanistan to Pakistan in 1981 was twice that of the local population as the refugees originated from an area of lower transmission and therefore, had lower immunity.⁴⁴ Under-fives are a particular high-risk group and make up to 15%-20% of total displaced populations.⁴⁵ The risks are likely to be even higher for orphans. Unaccompanied children, mostly orphans, had higher mortality rates (20-80 times per higher) than precrisis under-fives mortality rate in the Goma refugees camps during the Rwandan conflict in the 1990s.⁴⁴

Child Soldiers 

The worst examples of the latter practice were seen in Africa and have also been reported from Sri Lanka and Afghanistan. A detailed assessment of the dimensions of child labor and the direct effect and consequences of war on child soldiers is beyond the scope of this article. However, a reference must be made to the relationship of the Afghan war and conflict in Pakistan to the growth of the Taliban and conscription of children and adolescents to Jihadi (holy war) organizations.

Although the growth of religious extremism and fanaticism is by no means restricted to the illiterate, the most ready conscripts to the philosophy of violence are the adolescents and youngsters who are a product of conflict, and see little future and hope in the status quo. The disenchantment of a growing number of poorly educated if not illiterate, and unemployable youth in the region is a fertile source of recruits for right-wing religious extremist groups. This phenomenon is compounded several folds by the apathy of the state towards human development and promotion of equity. Writing on inequality and the growth of obscurantism and terrorism in the region, Kaiser Bengali a prominent social scientist writes:

Unequal societies are unjust societies. And unjust societies lose their moral and political legitimacy. Attention to the problem of income and regional inequality is thus not only important but also urgent. While poverty causes hardships and deprivation for those caught in the poverty web, inequality causes a sense of grievance and injustice, promotes despondency and anger, and generates social and political instability and even violence. Terrorism is a buzzword today, but those who are concerned about terrorism should pay close attention to the problem of inequality.

This worrisome epiphenomenon is by no means restricted to the conflict zones of Afghanistan, Pakistan, and Kashmir, but has found its way into the streets of Palestine in a growing number of teen age suicide bombers, as well as the murderous gangs of right-wing extremist youngsters in Indian Gujarat.

In many societies, there is inequality between girls and boys and this is also visible in times of conflict. In Afghanistan, the Taliban regime restricted access to education, health care, and employment for women creating considerable suffering and impoverishment to war widows and families in Afghanistan. The effect of these policies on the health and nutrition of women and adolescent girls was corroborated by several surveys indicated the disproportionate impact of food shortages and malnutrition on Afghan girl children.⁴⁷ Less obvious were the psychological trauma and mental stress that many resident Afghan women and families endured on an almost daily basis.⁴⁸ Such effects have been well described among residents and refugee women and children in other conflict zones as well.³¹, ⁴⁹

Sexual abuse affects both girls and boys, but girls may be more at risk. During the Rwandan genocide almost every girls over 8 years of age reported sexual abuse. The consequences of sexual abuse include human immunodeficiency virus infection, sexually transmitted diseases, suicide, unsafe abortions, and genital injuries.⁴⁶ In war-affected populations, access to gynecological health services is severely limited, further worsening the situation for young girls and women.⁹

Millions of children are killed by armed conflict, but 3 times as many are seriously injured or permanently disabled by it.⁵⁰ According to WHO, armed conflict and political violence are the leading causes of injury, impairment, and physical disability and primarily responsible for the conditions of over 4 million children who currently live with disabilities. In Afghanistan alone, some 100,000 children have war-related disabilities, many of them caused by land mines.¹², ⁵¹

Even before conflict, children with disabilities are a marginalized population. Only 2% of the world's disabled people are likely to receive formal rehabilitation services.⁵² Children with disabilities are already exposed to increased risks of violence and abuse but often this is not addressed.⁵³ The lack of basic services and the destruction of health facilities during armed conflict usually mean that children living with disabilities get little support and may be even further marginalized. In practice, disability is rarely considered in humanitarian programs. In 2004, the Sphere Handbook, a key text for humanitarian personal included disability as a crosscutting issue, but much more effort and training is necessary to ensure the specific needs of this population are not overlooked in humanitarian responses to conflict.⁵⁴

Further, the provision of prosthetics to children who acquire physical impairment during the conflict is an area that requires increased attention and financial support. In Angola and Mozambique, less than 20% of children needing them received low-cost prosthetic devices; in Nicaragua and El Salvador, services were also available for only 20% of the children in need.

Strategies to Support Children Affected by Conflict 

The aforementioned sections indicate the myriad effects of war on children in conflict zones and to the nihilistic among us, an almost irretrievable situation. However, others see in these unique circumstances, enormous opportunities for intervention. The developed world may not be into “nation building” but owes it to the women and children affected by armed conflict. Although greatly traumatized by 2 decades of war, one can draw some hope and faith from the relative resilience of children.⁵⁵ Although the psychological trauma of war on children has been described as permanent,⁵⁶ others disagree²¹ and place great faith in the potential of community and social structures in buffering these effects. Kinra et al⁵⁷ have also highlighted the ameliorating effects of good primary care systems on the children surviving the Bosnian conflict. However transient, others have documented the fact that children respond rapidly to the onset of peace with remarkable adaptation.⁵⁸

These intervention strategies can be largely grouped as follows:

Preventive strategies and upholding child and family rights during conflicts: It must be highlighted that provision of security and safety to children during conflict is principally an adult responsibility and all the charter of child rights must be strictly adhered to. Psychosocial readaptation and rehabilitation also presupposes a certain degree of physical security and economic stability before an adolescent is prepared to, or even able to, come to terms with the experiences of armed conflict. Thus, reestablishment of primary health care services and provision of basic housing and food is of vital importance.

Most children who experience violence need special care and attention. The family is the basic and most important ingredient in a child's physical and psychological rehabilitation and thus every attempt must be made to keep the family unit intact in conflict zones. If the assistance to children is going to make a meaningful difference, psychosocial support must also be offered to the parents as well as the children.

Recognition of psychological stress and early intervention (individual and public health levels): An important part of any intervention program is the recognition of high-risk groups and those with urgent needs. A number of strategies and screening programs have been identified as useful in screening children suffering from PTSD in diverse situations like Bosnia and Herzegovina, Kosovo, Chechnya, and Palestine.³², ³³, ⁵⁹ The relative prevalence of PTSD and depression has been recognized to be as high as 68% and 18%, respectively.⁵⁹ It is important that early recognition of these problems is coupled with rehabilitation programs and positive interventions. Although the evidence base for effective interventions is relatively small, these may be considered under the following available categories.

Education and schooling strategies: Of all the possible intervention strategies, educational approaches appear to be the most promising. These presuppose the rapid introduction of regular schooling and educational activities. There is usually a paucity of mental health professionals in developing countries, teachers can play a special role in the recognition and amelioration of stress. Many children suffering from PTSD will have difficulty functioning in a school setting. Teachers describe students as having short attention spans, exaggerated startle reactions, and either a lack of emotional availability or lack of affect. The child's ability to concentrate and learn can be increased by incorporating classroom activities stressing relaxation, group support, and problem-solving skills. The experience from Bosnia and Herzegovina of such approaches is both heartening and instructive.⁵⁹ Teachers from local cultural settings can be rapidly trained in basic stress recognition and counseling strategies employing culturally relevant and acceptable tools. Such graphic and painful material that traumatized children discuss or act out can also impact the teachers and other mental professionals working with trauma victims often develop painful images, thoughts, and feelings. This is referred to as vicarious or secondary traumatization. It is especially likely to happen when dealing with serious trauma of children. It may thus be important to put mechanisms in place to provide emotional and psychological support and stress relief to teachers and other health professionals. Peace and tolerance education in school curricula is also a valuable resource tool for educators.

Promotion of healthy sports and recreational activities: These activities have a special role in stress relief and rapid restitution of normalcy. The activities should focus in particular on group activities, team play, and sportsmanship. Care must be taken however, that sports in multi-ethnic environments do not become surrogates for violence and polarization of children or groups.

Support healing programs rather than focus on the negatives and psychosocial stress alone: Although the recognition of overt and subliminal problems is the key, it is also important that professionals and community groups focus on the positive and actively promote optimism and healing. Thus, deliberately highlighting positive outcomes and promoting concrete activities such as group activities, vocational training, and extracurricular activities are important. No matter how difficult or artificial, deliberate promotion of normalcy is extremely important for children and adolescents.

Special role of parents and truth commissions: A special mention has been made of the key role that health professionals and teachers play in rehabilitating children and adolescents after war and the importance of restoring normalcy. However, in certain circumstances communal healing maybe important and particularly adolescents may benefit from such a process. Truth commissions, human rights commissions, and reconciliation groups can be important vehicles for community healing. To date, 16 or more countries in transition from conflict have organized truth commissions as a means of establishing moral, legal, and political accountability and mechanisms for recourse. In South Africa and Guatemala, the commissions are aimed at preserving the memory of the victims, fostering the observance of human rights and strengthening the democratic process.

Table 5 highlights some key messages for the Global Child Health Community.

TABLE 5. Key messages for the global child health community

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Conclusions 

To summarize, no matter how disastrous the conflict, how tragic the impact on its children, there is roomfor optimism in the future and hope. It is important to create, strengthen, and expand programs for family support, education, improved nutrition, and protection of human rights in conflict zones. These programs must be based on solid foundations of political stability, forgiveness, and human development. In the current conflict-affected areas of Pakistan, the smiling faces of numerous Pakistani girls attending schools are a testament to the fact that humanity can triumph when given a chance. However, the lessons learned from humanitarian responses to armed conflicts must lead to strengthening intervention strategies that protect children in the future.⁶⁰ The ground breaking report by the UN commission headed by Graca Machel¹⁰ laid the foundations for protective mechanisms to prevent and ameliorate the effects of war on children and adolescents. It is now up to the global community to ensure their implementation.

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• 1 Based at the Hospital for Sick Children, in Toronto, with partners and participants around the world, the PGPR works with researchers, societies, nongovernmental organizations, and governments all over the globe to address global health issues affecting infants and children. PGPR informs, educates, facilitates international research collaboration, and advocates for research and cooperation to improve the health of all children.