Impact of War on Children and Imperative to End War

Younger readers of this journal may themselves have been exposed to war during their teen years. Much has been written on the subject in the last two decades – how war affects children, how to rehabilitate war-affected children (tertiary prevention), and how to make the experience of being in a war zone less damaging for children (secondary prevention). However, any degree of immersion in the suffering of children in war impels one to consider ways of removing the vector producing the suffering – war itself (primary prevention). While in a previous essay in this series (1), I considered ways to prevent specific wars, here I will consider a broader issue of replacing our present war system with a peace system.

The impact of war on children

War affects children in all the ways it affects adults, but also in different ways. First, children are dependent on the care, empathy, and attention of adults who love them. Their attachments are frequently disrupted in times of war, due to the loss of parents, extreme preoccupation of parents in protecting and finding subsistence for the family, and emotional unavailability of depressed or distracted parents. The child may be in substitute care with someone who cares for him or her only slightly – relatives or an orphanage. A certain proportion of war-affected children lose all adult protection – “unaccompanied children,” as they are known in refugee situations.

Second, impacts in childhood may adversely affect the life trajectory of children far more than adults. Consider children who lose the opportunity for education during war, children who are forced to move into refugee or displaced person camps, where they wait for years in miserable circumstances for normal life to resume, if it ever does. Consider a child disabled in war; they may, in addition to loss of a limb, sight, or cognitive capacity, lose the opportunity of schooling and of a social life. A girl who is raped may be marginalized by her society and lose the opportunity for marriage. Long after the war has ended, these lives will never attain the potential they had before the impact of war.

Listing the impacts of war on children is a sadly straightforward task:

Death. Hundreds of thousands of children die of direct violence in war each year (2). They die as civilians caught in the violence of war, as combatants directly targeted, or in the course of ethnic cleansing.

Injury. Children suffer a range of war injuries. Certain weapons affect them particularly. A landmine explosion is more likely to kill or seriously injure a child than an adult (3). Thousands of children suffer landmine injuries each year (4).

Disability. Millions of children are disabled by war, many of whom have grossly inadequate access to rehabilitation services. A child may have to wait up to 10 years before having a prosthetic limb fitted. Children who survive landmine blasts rarely receive prostheses that are able to keep up with the continued growth of their limbs.

Illness. Conditions for maintenance of child health deteriorate in war – nutrition, water safety, sanitation, housing, access to health services. There may be loss of immunity to disease vectors with population movement. Refugee children are particularly vulnerable to the deadly combination of malnutrition and infectious illness. There is also interruption of population immunization programs by war which may be responsible for increases in child mortality.

Rape and prostitution for subsistence. These phenomena which often occur in situations of war, ethnic cleansing, and refugee life leave lasting physical impacts in sexually-transmitted diseases, including HIV/AIDS, psychological impacts and changes in life trajectory.

Psychological suffering. Children are exposed to situations of terror and horror during war – experiences that may leave enduring impacts in posttraumatic stress disorder. Severe losses and disruptions in their lives lead to high rates of depression and anxiety in war-affected children. These impacts may be prolonged by exposures to further privations and violence in refugee situations.

Moral and spiritual impacts. The experience of indifference from the surrounding world, or, worse still, malevolence may cause children to suffer loss of meaning in their construction of themselves in their world. They may have to change their moral structure and lie, steal, and sell sex to survive. They may have their moral structure forcibly dismantled and replaced in training to kill as part of a military force.

Social and cultural losses. Children may lose their community and its culture during war, sometimes having it reconstituted in refugee or diaspora situations.

Child soldiers. It is estimated that there are tens of thousands of young people under 18 serving in militias in about 60 countries. They are particularly vulnerable to all of the impacts listed above (5).

Remedial strategies

Action on this cluster of tragic phenomena is usually considered under two categories – how to mitigate some of the damage to children and how to heal children after they are damaged.

Making war less damaging to children (secondary prevention)

1. Implement international humanitarian law regarding the protection of children in war. The Geneva Conventions and the Convention on the Rights of the Child deal with protection of war-affected children with regard to food, clothing, medicine, education, and family reunion. In addition, they are intended to protect children from ethnic cleansing and recruitment into armed forces. However, compliance with these instruments is poor, especially when recruiting children to armed forces is concerned.

2. Ensure that general economic sanctions against a country are never used again, as they were used in Iraq as a substitute for war. Children and poor adults are those who suffer most from economic sanctions. Use of economic sanctions should be considered a war crime, just as is laying siege to a city to starve its population.

3. Ensure special consideration for children who are in flight from war zones and who live in camps for refugees and internally displaced people, especially children who are unaccompanied by adults. Special considerations need to be given for family reunion, systems of distribution of resources (sometimes to women rather than to men), internal layout of camps (to prevent attacks on girls), the provision of facilities for education and play, and special help for child-headed families.

4. Institute measures to reduce sexual exploitation and gender-based violence against women and girls in war. These measures include training of soldiers, including peacekeeping forces; inclusion of relevant interventions in humanitarian responses to population emergencies in war; reporting and support systems for victims of rape in camps for refugees and internally displaced persons; the prosecution of rape as a war crime; and making organized rape a crime against humanity.

5. Parties to a conflict must facilitate humanitarian assistance to ensure that the health infrastructure of children’s lives is not destroyed. Perpetrators should be prosecuted for such actions as destroying clinics, schools, and hospitals – all of which are protected by international law. Where access to health services, such as immunization, is hindered by the violent conflict, there should be humanitarian ceasefires to enable access.

6. Include children’s interests in peace agreements. Since 1999, several peace agreements have specifically referred to children in the post-violence arrangements for disarmament, demobilization, and reintegration (6). Children are recognized as victims and perpetrators of violence in several truth-and-reconciliation commissions, but children have played little role in these systems.

Rehabilitating children affected by war (tertiary prevention)

During the immediate humanitarian response to victims of war and in the longer-term attempts to reconstruct health services after war, there are attempts by both local and international actors to care for children’s needs for health care. Physical and psychological rehabilitation is instituted to varying degrees depending on the resources available. Sometimes these are minimal or absent. There have been many efforts to help the psychological impacts of war on children. Few have been evaluated.

Some efforts at rehabilitation of war-affected children include social healing moving toward education in the Culture of Peace. This is an approach to primary prevention of recurrence of war.

Imperative to end war

It may strike the reader that, although the many efforts to make war less damaging for children are important and should continue and be strengthened, this is a pathetically feeble response in the light of the intensity and magnitude of the suffering involved. From a certain perspective, there is even something preposterous about an exclusive focus on making war more tolerable for children. We rail against approaching HIV/AIDS, tuberculosis, or malaria in this way. Poverty, on the other hand, like war, may be treated with the assumption that it will always be with us, and is a fact of life. These assumptions should be vigorously challenged.

• War is a recent phenomenon in human evolutionary history. For most of our species’ existence there is no evidence of war.

• There are many current cultures without war.

• In the European Union, social institutions for dealing with conflict have evolved to a point where war is unthinkable between member states.

• There are clear alternatives to war in dealing with intra- and inter-state conflicts.

• Judicial process: The World Court resolves many interstate conflicts.

• Democratic functioning is designed to resolve intra-state conflicts. Good design of constitutions is another factor in this function.

• Dialogue: UN conflict management capacities already quietly resolve many serious conflicts. Better resourcing could enhance these capacities. Other agencies also act in this mode.

• Nonviolent struggle is frequently successful in deposing dictators or dysfunctional regimes. Usually this is done without good organization or training. Such efforts could be even more successful with these resources added.

• Cultural change from endorsement and support of violence in conflict response to support and knowledge of peace processes. Consider cultural change in Sweden over the last few centuries from a belligerent country to a peaceful one. UNESCO has worked specifically to promote a culture of peace.

It is time for health professionals to define war as a serious global public health problem. The public health imperative is primary prevention – removing the vector of illness or making conditions unfavorable for survival of the vector. If a peace system can be devised for an entity as large, diverse, and populous as Europe, it can be devised at a global level. It would be naive to suggest that this is easily achievable. But it would be cynical, in the light of the suffering of the war-affected children of the world, to accept war as an inevitable part of the human condition. There are global networks, formal and informal, of health professionals who think in terms of eliminating war and who work to accomplish this. International Physicians for the Prevention of Nuclear War (IPPNW) is such a network, particularly focusing on the role of health professionals working to eliminate war (7). A network with the same goal is TRANSCEND, a peace and development network which includes several physicians (8).