War and Children

Children ensure the survival of society. Adults are entrusted with their well-being, including the daunting challenge of protecting children against the violence of war. War continues to evolve in response to geopolitical transformations with large-scale wars being replaced by regional conflicts and international terrorism. Modern versions of war disproportionately affect civilian populations including children.^{1 - 3} According to the United Nations Children's Fund, the proportion of civilian casualties of war has increased from 5% to 90% during the past 2 decades, with children accounting for at least one half of the casualties,^{1 ,4} and more than 1.5 million children have died as a result of violence between the years 1990-2003.⁴ During the violent civil war in Rwanda, 300 000 children were brutally killed over a 90-day period.⁴ Similar catastrophic situations are found today in the Darfur region of Sudan and the Congo.⁵

However, these appalling figures do not begin to portray the extent of the human-made catastrophe affecting children. Many more children are physically maimed than are killed in war-related violence.⁶ Mortality related to the lingering effects of war is often higher than that occurring during actual fighting.^{1 ,4 ,7} Disrupted health and social services are incapable of dealing with the basic needs of children leading to epidemics, starvation, and extreme neglect.⁷ Landmines and unexploded ordinance continue to extract a deadly toll, accounting for an estimated 15 000 to 20 000 casualties per year with a third of these being children.⁴

Children also experience serious psychological trauma resulting from exposure to violent events, loss of caregivers, and forced removal from their homes.^{1 ,4 ,6} More than 12 million children have been displaced from their homes as a result of war and associated human rights violations during the decade spanning 1985-1995, and the most recent data from United Nations High Commissioner for Refugees does not show much improvement.^{6 ,8} Moreover, during periods of war, children are more susceptible to exploitation in the form of forced conscription as soldiers, sexual abuse, and slavery. At least 300 000 soldiers younger than 18 years are participating in military conflicts worldwide.⁹

During war, social inhibitions and cultural norms that bind societies break down. Driven by hate or ideological fervor, individuals or groups have no hesitation attacking children. Aberrant behavior such as rape and torture, which would be inconceivable for most people during times of peace, are common during war.^{10 - 11} The extent of human suffering experienced during war is sometimes so great that natural instincts such as parents' desire to protect their children may be diminished.¹ For instance, some reports include parents selling children into slavery or condoning their use as suicide bombers.

War affects both children and adults, but children are more susceptible to the consequences of war especially the youngest ones.¹² Children lacking the physical or intellectual capabilities to defend themselves are easy targets. Younger children, because of their small size and immature physiology, are highly susceptible to disease and starvation and more likely to sustain fatal injuries from ballistic projectiles and explosive devices.² Parents, who under ordinary circumstances would care for and protect their children, may be absent or preoccupied with the struggle to survive.

Exposure to traumatic events associated with war and violence may have long-term consequences for a child's psychosocial development.¹³ Children who are exposed to war and terror are at risk of developing traumatic stress reactions and have high rates of depression, disruptive behavior, and somatization disorders.^{13 - 14} Displacement, loss of caregivers, physical suffering, and a lack of appropriate socialization are additive factors that can compound the effects that war and terror have on a child's psyche.¹⁵ Loss of parents and the absence of social inhibition together with physical insecurity and hunger may lead children and adolescents to prostitution, crime, and social violence. Lacking stability, children may choose to emulate inappropriate role models, such as terrorists and gang leaders. Motivated by the desire for revenge and adventure, they may be quick to join in the fighting.^{1 - 2}

News media exposure may exacerbate the psychological effects of war on children. During the past generation, media coverage of war and terrorist events has become more graphic. The extended coverage, especially that provided by television and the Internet, generates a multiplier effect for acts of violence via its impact on children who are geographically distant from the epicenters of war. Uncensored pictures of victims, unbridled violence, or family members searching for relatives may traumatize children and serve as a stimulus for inappropriate behavior.¹⁶

Physicians and other health care professionals can play a leading role in protecting children against the ravages of war. Efforts to protect children from war need to be focused on prevention and rehabilitation. At the international and national levels, preventing war-related violence against children involves effective deterrence. Individuals perpetrating violence must be made to realize that they will be held accountable for human rights abuses. Such awareness may be encouraged if international conventions detailing the appropriate treatment of children during times of war and the penalties for violating the rights of children are enforced.¹⁷ Effective enforcement requires public awareness and detailed documentation of war-related casualties and human rights abuses. Physicians, based on their training and experience, are eminently qualified to document human rights abuses during times of conflict, and their testimony is often afforded great credibility.¹⁸ Physicians participating in international relief efforts often have unique access to war zones, allowing them to probe and record war-related crimes. Medical journals that are willing to publish articles on war can serve to heighten the awareness of both the medical community and general public. Such activities may help to generate pressure on the international community to intervene in ongoing conflicts.

Another way physicians can help in wars and civil conflicts, especially in low-intensity conflicts, is to promote productive communication and interaction. Physicians caring for individuals on both sides can initiate dialogue between the factions. Building on the shared belief that children need to be protected from the effects of war, physicians can work together in promoting child health. This can take the form of collaborative research, shared patient management, and joint conferences focusing on child welfare. The constructive discourse between physicians can often be extended to include both patients and policy makers, and these efforts can be the first steps toward peaceful coexistence and moral reengagement.³

Another important role for physicians is combating dehumanization that allows for the acceptance of childhood suffering.¹⁹ Physicians are often exposed to the trauma of war¹⁸ and have first-hand knowledge of the suffering of innocent children and can bear witness to their pain. As those charged with maintaining the physical and emotional well-being of their youthful patients, physicians and health care professionals have the responsibility of protecting the human rights of children and promoting the concept of “zero tolerance” with regard to violence directed against children.¹⁸

A major focus for the medical community is the treatment and rehabilitation of children injured or otherwise harmed by war. Rehabilitative efforts are divided into 2 phases: immediate relief efforts and long-term follow-up care. The success of immediate relief efforts depends on the rapidity, magnitude, and quality of the response. Similar to all forms of disasters, rapid and efficient intervention can be lifesaving. Developing disaster plans and drills focusing on the treatment of ballistic, explosive, chemical, biological, and psychological trauma as it relates to children is critical. Similarly, it is important to educate health care professionals about the unique requirements of children during war-related disasters.²⁰ Recommendations have been formulated for terror-related incidents involving children.²¹ However, these recommendations are mostly valid for countries with well-developed health care systems. For developing countries that lack infrastructure and need to rely on external relief efforts, specific guidelines for dealing with the aftermath of disasters involving noncombatants have been formulated.²² Sufficient resources must also be allocated to relief efforts, but given the persistently high rates of childhood morbidity and mortality related to war, the efforts of international relief agencies often seem inadequate.²³

Similar to rapid response efforts used for responding to natural disasters such as earthquakes, the same guiding principles could be used to develop an international rapid deployment force consisting of relief staff, medical workers, and mental health professionals who can be mobilized quickly in response to impending war-related disasters involving children. This force could operate under the auspices of either the World Health Organization or one of the United Nations agencies devoted to the care of refugees and who have expertise with emergency relief efforts. The immediate aim of this force would be to protect exposed children by removing them from the actual battle zone, facilitating family reunification, and initiating medical and psychological interventions to prevent war-related diseases and acute stress reactions. Such an initiative would require substantial investment by the international community. This can only occur if protecting children from violence and terror becomes a foremost global priority.

Long-term, children recovering from the aftermath of war need continued follow-up especially in terms of their mental health. Rates of posttraumatic stress disorder (PTSD), depression, and other psychological disorders are extremely high among child survivors of war.^{13 - 15} Factors that increase the risk for and severity of mental disorders include duration and intensity of exposure to traumatic events, availability and quality of family support, the amount of life disruption (eg, displacement), and the level of support that can be provided by local social support systems.¹³ The worst forms of psychopathology are seen in children with prolonged exposure to violence or chaotic situations.¹³

Specific manifestations of PTSD in children are age-related, and treatment interventions have to be commensurate with the developmental stage of the child. Treatment of PTSD in children is complex. Most important, the child or adolescent has to be restored to a safe and caring environment.²⁴ If relocation is necessary, consideration should be given to the social background because culturally appropriate care can improve the outcome.²⁵

It could be argued that singling out children for special treatment during war is the wrong approach. The impact of war is felt by all groups, and a more logical course would be to prevent war by addressing the social inequities and injustice that lead to physical strife. Unfortunately, the experience of the past decade has shown that many conflicts are not easily resolved especially those rooted in ethnic or ideological differences. Given the situation, efforts should be directed at mitigating the effects of war on children because of their increased vulnerability and their innocence. As succinctly put by Machel, a well-respected advocate for children's rights, “children are both our reason to struggle to eliminate the worst aspects of warfare and our hope for succeeding at it.”¹