Effects of war—a sadistic catalogue of abuse

Three and a half centuries later, life for many children is still as Hobbes described it. Up to two million children have been killed in war zones in the last 10 years2; often painfully, without medical care, and sometimes alone. A further four million have been permanently disabled. They serve as a constant reminder to their parents of the horrors the family has been through, if they still have parents. One million children have been orphaned. This may be the greatest loss conceivable, but not the greatest number who have lost. Twelve million children have been displaced from the security of their homes and one third of these have spent time in the restrictive and abusive confines of a camp for refugees or internally displaced persons. Some have been incarcerated in concentration camps.

Secondary effects

Numbers such as these do not tell the whole story, however. Death and suffering in the aftermath of the fighting continues to affect the most vulnerable, usually the children under 5 years of age. Malnutrition after the wilful destruction of crops, or the more subtle denial of fertile lands by the indiscriminate laying of antipersonnel mines has its greatest toll among families with young children. Unrecognised and untreated illnesses, and the obvious sequelae of destroyed or impoverished health systems, may have an impact that takes years to reverse. Disruption of previously effective national immunisation programmes places whole cohorts of children at risk in epidemics which should have been relegated to medical history. In Kosovo province, in the Federal Republic of Yugoslavia (Serbia), there has been a recent epidemic of poliomyelitis (D P Southall, personal observation).

International response—not always beneficial

The response of the international community, designed to punish the aggressor or ‘contain the conflict’, may sometimes have its greatest adverse effects on innocent families who are trapped in a political system, not of their design, which they cannot change, and which they do not support. Various forms of ‘collateral damage’ have been recorded after the international sanctions imposed against Iraq,3 with a quadrupling of the incidence of severe malnutrition in children under 5 years of age over a four year period after the imposition of sanctions.4 Children in Serbia have undoubtedly suffered under the ‘triple burden’ of war, loss of trade between the republics of former Yugoslavia, and UN sanctions.5 6 Whenever the international community acts to intervene in a war, the consequences to children, families, and society must not be viewed dispassionately or removed from the wider, moral context. In this respect, all children—as outlined in the UN Convention on the Rights of the Child—are equally important, whatever their colour, race, or ethnic origin and wherever they happen to be living at a particular time.

Child soldiers

The age at which children may legally be recruited into an army varies from country to country. Specific articles of international humanitarian law state that persons under the age of 18 years should be respected as children,1 but the same humanitarian law fails to offer protection from military service to children who have reached their 15th birthday. Attempts to redress this injustice have failed because of lack of support from some of the more prominent sponsors of the UN (table 1). Although there is no conscription or national service in the UK, the active recruitment of 17 year old boys into the army7 may send the wrong signals to other countries. The already abusive situation that exists is further compounded in those countries where an unscrupulous regime recruits in the absence of adequate birth registration. This allows for the possibility that children under 15 years of age will be conscripted.

Forced conscription of boys and girls provides a rich harvest of compliant, yet dispensable, combatants. They are ideal for the purpose because they require little training to be able to disassemble or discharge the ubiquitous lightweight assault rifle (a fully loaded Kalashnikov AKM weighs only 3.1 kg).8 Child soldiers are cheap to maintain, relieving those in power of the need to finance or otherwise support services such as education. In long running conflicts, the military imperative means that, as supplies of adults are exhausted ever more youthful cohorts of children are pressed into service. It is no longer unusual to find children as young as 10 years bearing arms. In Afghanistan, after more than 17 years of war, it is estimated that up to 45% of soldiers are under 18 years of age.9 Drugs, alcohol, and violence, physical and psychological, have been used by military organisations in brutal induction ceremonies where children may be compelled to kill others, including their own family members.9

Torture

Children have been detained and tortured in the pursuit of military objectives. Torture of children may be used as part of a collective punishment of a community, as a means of extracting information from the child, the child’s peers or parents, or as entertainment. Allegations of cruelty to children as young as 12 years—involving solitary confinement while naked and blindfolded, beatings, electric shocks, and hosing with cold water—have all been documented by Amnesty International and corroborated by medical evidence.10

Gender based violence

Nor is it just boys who are abused in this way. There have been many reported instances of adolescent girls being conscripted into armies to look after the troops in more ways than just cooking and cleaning. Rape as a crime of war is not restricted to adult women.11 It has been used as a tactical weapon of war to humiliate and weaken morale, forcing terrorised civilians to flee. It has also been practised with the intent of ethnic cleansing through deliberate impregnation as described in Bosnia and Herzegovina and in Croatia.12 The risk to adolescent girls, increased because of their size and vulnerability, is even greater in those areas where sexually transmitted diseases (including AIDS) are endemic, because they are considered less likely to be infected. Rape also affects those children who have witnessed, or are ostracised because of, the rape of their mother or other family member.12 13

Children fall victim to these abuses as the protective functions of the family and society are eroded by war. They are easier pickings if they have been orphaned or separated from their carers. Some will have been sold to the army, the only commodity an impoverished, uneducated, and frightened family may have. Parents may have been persuaded that the training and arming of their children will offer the children greater stability and protection in an uncertain world. Children may have ‘volunteered’ for this same reason, believing that they might somehow be able to protect their family. This was never a free choice. Adolescents, who, having lost all else, are developing a sense of identity may ‘join up’ to protect themselves from the social chaos. They may feel that belonging to an organisation will give their lives some structure or purpose, particularly if freedom from oppression is a purported goal.

The desensitisation that must accompany repeated exposure to violent and traumatic experiences may make a child more likely to engage in violent and antisocial activity long after the conflict is ended, making reintegration more difficult, thus perpetuating the cycle of brutality. It is difficult to imagine a youth of 16 years who left home as a child aged 12 years being able to adapt to life within a family and society where he is expected to put down the gun and go back to school with peers in an atmosphere where the frustrations of poverty and injustice remain, where his new found assertiveness and independence may not be valued so highly.14 One of the results of the failure of warring parties to recognise publicly that they had enlisted child soldiers is that there is no account taken of their very different needs in the demobilisation process after the war is over. Successful reintegration requires the support of community and family, school and peers, all of which may have been disrupted beyond recognition.

Psychological effects of war

The psychological effects of war on children are sinister and extremely difficult to document. They touch many more children than are affected by physical injuries and are less likely to be treated effectively. Growing up within a society whose norms and values have been perverted by war is bound to have profound effects expressed in many different ways. We have failed to recognise these effects in the past. Children were viewed as having a lesser understanding of events such as war and they were felt to have a greater ability to adapt psychologically to war’s stresses. It was therefore suggested that subsequent behavioural disturbances should be less severe.15

Psychological effects of war depend on the age, sex, personality, and previous experiences of the child and on the child’s culture. The nature of events and the extent of the child’s exposure are also important.16 Effects are further modified by other consequences of war, such as physical injury, loss of family members, and loss of family home and community support. Children do present the hallmarks of post-traumatic stress disorder,17 with recurrent, intrusive and distressing recollections of disturbing thoughts and sensory images. They may re-experience the events through other behaviours such as dreams, story telling, or play.18Depression and anxiety disorder are common.13 19 20

Attitudes and values may be distorted in the moral vacuum created by war. In children exposed to the terror of shelling nearby, there is evidence of an increase in aggressive attitudes, expressed through increased patriotic feelings. Such children have also been found to place greater value on displays of courage by their peers.21 Such displays may in themselves be self destructive, for example playing with the snipers, by taunting them, in one of the ‘sniper’s alleys’ in Sarajevo (M C B Plunkett, personal observation). It is then just a short step from playing at war games to participating in the real thing.

The opportunity to play an active part in what is seen as the community’s struggle and thus have some control over one’s responses to the stresses of war may be protective in terms of psychological outcome for some children.22 Children are prone to feel guilt and in a situation of armed conflict, although they may have been forced to grow up and adopt an adult role, they remain emotionally immature. The naïve trust of a child in such circumstances is all too often betrayed by those who determine the pace of the war. If the participation is at the level of being a child soldier it will further burden the adolescent psychologically in the long term.

Changing face of war

The modern battlefield has been labelled as empty,23a reference to the ‘hi-tech’ manner in which wars are prosecuted with little emphasis on ‘hand-to-hand’ fighting. Unfortunately this does not give the whole picture. Wars are no longer fought on a battlefield, or more correctly, the topography and the definition of the battlefield have changed. It is no longer the place where soldiers are found loading munitions into big artillery pieces, but rather the towns and cities populated by civilians, with playgrounds full of children and marketplaces full of mothers. One similarity remains: it is still the place where the artillery rounds land. It is changes such as this which are responsible for the changing face of war mortality figures. Civilian casualties numbered 5–19% of total casualties in World War I; it is estimated now that they can account for up to 90% of fatalities in some wars, particularly those occurring within a single state (table 2).

Preventing the tragedy

In considering intervention in a ‘foreign war’, those in advantaged countries tend to fall into the comfortable trap of blaming politicians for allowing a situation to develop and holding them responsible for the deaths of combatants in the battlefield. We should examine our consciences when we consider the deaths of infants and children, whether directly as a result of the battle zone that has visited the classroom, playground, or marketplace, or indirectly as a result of the privations of war. The well reported incidences of atrocities on a national scale (amounting to genocide) do not develop overnight. There are warning signs, such as discrimination, increasing repression and politically or ethnically sponsored violence, often coexisting with severe poverty (for the majority at least!). The concern that should be raised by such a rising tide of nationalism could be better focused if heed were taken of some of the cultural preconditions recognised by Staub.24 These include expansionist and nationalist tendencies, cultural or historical perceptions of superiority and a right to rule in the presence of a rigid, class ridden society that has a low tolerance of disobedience.

Such concerns should be heeded and acted upon. They should not be over-ridden by political considerations. Delays on this account should be denounced as complicity. Surveillance is necessary, to record the development and extent of atrocities as well as determine responsibility. The early collection of the necessary evidence to indict war criminals may have some preventative value, as a more efficiently functioning international legal framework may dissuade would-be despots.25

World events have provided us with ample opportunity over the last 20 or more years to gather enough information on the effects of war on children, from psychological to physical, from war injuries to malnutrition and disease epidemics. The time is now ripe to discuss the place of advocacy and direct intervention on behalf of children affected by war. We should move forward from a position of describing the natural history of the ‘disease process’ and while still trying to treat its effects, begin effective preventative programmes.

Strategies to protect children from the effects of war

USING THE UN CONVENTION ON THE RIGHTS OF THE CHILD

The thread running through the UN Convention on the Rights of the Child has three strands. They can be identified in many of the individual articles that constitute the whole, and together, if recognised and judiciously applied, can effectively ensure the protection and safe development of the child.

• In providing for children, a ‘best interests’ rule should be applied. Those responsible for determining policies which affect children should ensure that the best interests of children are taken into account. The individual child is no less important in the eyes of this law. Those responsible for the individual child have a clear duty to ensure that their best interests are not subjugated to ‘the good of the greater number’.

• Participation in decision making by children of an age and ability to do so increases the likelihood that the decision will be appropriate and less liable to contravene their rights. Adolescents have long been recognised as being capable of making informed and appropriate choices.

• Non-discrimination should be the rule in the application of any policy to the individual or a cohort of children. Most abuses stem from a failure to enact this self evident concept.

Now ratified by (and therefore legally binding on) all but three countries in the world (USA, Somalia, and the Cook Islands), the UN Convention on the Rights of the Child should be seen as an effective tool in ensuring children’s rights. The USA is seen as a prime mover in determining, guiding, and also enforcing policy in many geographical and political spheres in the world. Somalia is a country whose children have an experience of poverty and war only hinted at in its under 5 year mortality rate, which is the 10th highest in Unicef’s 1997 listing.26

PAEDIATRICIANS’ ROLE

Waiting for effective leadership should not prevent the individual from playing their part in advocating the rights of children. Paediatricians are in a privileged position. They already have a reputation for listening to children and ensuring the child’s best interests are protected regardless of colour or creed. Their status in community and society gives them a platform from which to denounce the abusive effects of wars on children. Their knowledge of the effects of such abuse lends authority to their voice. Authority such as this might ideally be used to inform and mould international opinion and effect an appropriate response. The effects can only be positive. Although the problem is enormous, the real difficulty is overcoming the prevailing view that individual voices cannot influence change. We should be encouraged by Robert F Kennedy’s words to . . .‘Let no one be discouraged by the belief there is nothing one man or one woman can do against the enormous array of the world’s ills against misery and ignorance, injustice and violence . . .Each time he stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends a tiny ripple of hope, and crossing each other from a million different centres of energy and daring those ripples build a current which can sweep down the mightiest walls of oppression and resistance’.

RESPONSE OF INTERNATIONAL COMMUNITY

If the war cannot be stopped, efforts to minimise its effects on children might include:

• Obtaining agreement to exclude civilians and population centres from direct assault

• Removal of civilians from conflict zones

• Effective enforcement of the concept of ‘safe areas’.

Gentlemen’s agreements are difficult to obtain when all the gentle men have been killed or forced to flee. The true purpose behind the targeting of civilian refuges is obvious. Often based on ethnic differences, an atmosphere of distrust, fear, and envy and a desire for revenge is readily generated by destructive nationalistic devices where reason is displaced by a basic and brutal survival instinct. The eradication of an enemy ‘gene pool’ is then seen as a justifiable military objective.

Moving people from their homes in the face of an advancing army may sometimes be the only way to save lives. Indeed, all too often, it is the course of action taken by those so endangered. It can also be seen, however, as doing the army’s job for them. The end result may be the same, a form of ethnic cleansing by proxy. One ends up making refugees out of survivors, increasing their dependence on emergency aid systems ill prepared to cope. The best approach must be to stand by the children and their families, protecting them within their homes and communities.

EFFECTIVE SAFE AREAS

Internationally mandated, a zone of protection or ‘safe area’ could provide the support and security that children and non-combatants have as their right.27 These, by necessity, would be centred on population centres, be they cities or camps for refugees or internally displaced persons. Apart from the international community’s protection force, they should be devoid of any capability which might reasonably be construed as military. All persons living within them would have to be disarmed. Safe corridors would enable resupply and specialist medical or logistic support when needed. Rapidly deployed and adequately resourced, a proactive, military protection force would be able to prevent atrocities being committed against children on the scale we have witnessed in recent conflicts. Military assistance, supplied by, but not controlled by, foreign governments would have a simple mandate, complete protection of their charges. Such assistance should be provided in conjunction with a global war crimes tribunal, empowered to act at the onset, rather than the end, of a conflict.

It would be a further injustice to children to suggest that this has already been tried without success. The failure of similar attempts in the recent past owed much to what at times seemed like a half hearted commitment on the part of the protecting countries in the face of a determined onslaught. Srebrenica in eastern Bosnia is an upsetting example of how an ill prepared ‘protection force’ may increase the risk that a people under ‘UN protection’ may find themselves exposed to with tragic consequences.28 While the rest of the world was appeased with the information that a UN protection force was in control of the situation, an act of genocide (which unfortunately had had many precedents within each of the communities in the history of this conflict) was in progress.

The successful management of an effective strategy of protection requires a firm political resolve, sustained by the knowledge that this was the right thing to do. It also requires a collaborative effort between humanitarian and military agencies among which the required expertise almost certainly exists.

A foundation for good humanitarian practice

The principles of good practice used in the child protective procedures that form the basis of clinical paediatrics could serve as guidelines for intervention in such circumstances.

Intervention should be appropriate to the needs and circumstances of the child and family. The methods that have been developed to help tackle the manifestations of post-traumatic stress disorder and other psychological sequelae of war are an example of this.27 29

Accessibility could be ensured by siting resources (whether personnel or materials) within the target community. This becomes more important in areas where interethnic conflict or other factors, such as antipersonnel mines, restrict movement.

The legality of any intervention needs to be ascertained, particularly when dealing with individuals whose vulnerability stems from the fact that they have been deprived of all basic rights and all means of asserting them. Clear guidelines have been drawn up30 31 ; many have been embodied in an internationally ratified convention.1

Children deserve competent care. Those who work with children in advantaged countries are overseen by professional bodies. Children in more difficult circumstances need as much if not more protection from the good intentions of the incompetent. A code of conduct helps,32 as does UN recognition of non-governmental organisations that have proven track records. Sanctions may be necessary to dissuade ‘incompetent operators’.

Any service directed at children should undertake to ensure theprotection of the child. That the end result of an intervention is an improvement in the lot of children is not sufficient. An example from clinical practice might be performing an invasive procedure on a child without adequate explanation, analgesia or sedation. Just as reprehensible is the ‘smuggling’ across an international border of an unaccompanied child without regard for the child’s family or preserving the child’s identity.33 In advantaged countries legislation exists to protect children from adults who have committed certain crimes against children. Children caught up in humanitarian crises deserve the same protection. A process of screening for all who would work with such children should be established.

Intervention should be collaborative. The participation of parents, relatives, and community are considered essential in the treatment of children’s problems in stable, advantaged countries. These agencies are of much greater importance in situations of conflict where a child, disorientated by events needs the security that only the familiar can provide.

Interagency coordination should reduce waste and duplication.

This work needs effective audit. Efficiency and effect should be subjects for open discussion, not internal consumption. Transparency is possibly the most notable absentee from the list of features of the vast majority of aid agencies. The chances of an aid programme being funded at a realistic level are inversely proportional to perceptions of waste or fraud.

Arms sales and children’s rights—irreconcilable concepts

Events suggest that the concept of children’s rights is not an idea that stirs the minds of those in disadvantaged countries who promulgate war. The vast majority of arms sold to such regimes are derived from state sponsored companies in countries which have signed and ratified the UN Convention on the Rights of the Child.34 Such countries (including all the permanent members of the UN Security Council—see table 1) may deny complicity, but in creating a financial or political environment in which arms dealers may ply their wares, they should be deemed responsible.35 The exposure of an Isle of Man registered company as a significant arms supplier to one of the warring factions in Rwanda36 37 should concern successive British governments seeking to enact legislation to outlaw handguns and knives in their own jurisdiction. One cannot help but wonder how the UK, as a signatory of the UN Convention on the Rights of the Child and one of the world’s largest exporters of arms after USA, reconciles this inconsistent and morally objectionable position. It is unfortunate that this is inadequately balanced by the position of 14th (out of 21) that the UK held in 1995 in the list of donors of overseas development assistance (as a percentage of gross national product) to developing and disadvantaged countries.38 Now might be a good opportunity for all involved in such arms deals to read the preamble to the UN convention, and honestly ask themselves if the arms deal proposed represented a good way of ‘...recognising the importance of international co-operation for improving the living conditions of children in every country, in particular the developing countries...’, or of ‘...considering that the child should be fully prepared to live an individual life in society and brought up in the spirit of the ideals proclaimed in the Charter of the United Nations and in particular in the spirit of peace, dignity tolerance, freedom, equality and solidarity...’.