Adverse health effects of recruiting child soldiers

Introduction

A report published by Medact in 2016, The recruitment of children by the UK Armed Forces: a critique from health professionals, ^{1 2} brought together for the first time evidence highlighting the increased risk of death and injury for those recruited under the age of 18. It revealed the long-term impacts of the British military’s recruitment of children under the age of 18, presented evidence linking ‘serious health concerns’ with the policy and called for a rise in the minimum recruitment age.

What is the problem?

It is impossible to know the exact figure but it is estimated that there are tens of thousands of children in armed groups around the world. The UK is one of only a handful of countries worldwide to recruit children (defined as any person under the age of 18) aged 16 into the armed forces as part of state policy and is the only country in Europe and the only permanent member of the United Nations (UN) Security Council to recruit 16-year-olds. In March 2018, the number of under-18 army recruits was 2290, making up 21% of all army recruits.³

For clinicians, the recruitment of adolescents to the military is problematic because:

1. It denies the rights of the child, in particular the right to the ‘highest attainable standard of health’ and safeguarding from ‘physical or mental violence’, as well as the right to have their best interests as primary consideration in all actions related to them, including by lawmakers.⁴

2. Military service during adolescence causes specific health harms during this critical period of development.

3. The arguments for child recruitment are unfounded and unsubstantiated in the face of the evidence.

Ignoring the rights of the child

Young people are permitted to begin the enlistment process at the age of 15 years and 7 months, with 2 years of training beginning at the age of 16. Beyond their 2-year training period, they are then expected to serve in the UK Armed Forces for a further 4 years—taking them to the age of 22. Those recruited above the age of 18 are expected to serve just 4 years. Campaigners, health professionals and civil society have long argued that adolescents—who are unable to vote, purchase alcohol and sharp objects such as knives—are too young to be able to make the life-altering decision to enlist into the Armed Forces, and they risk becoming trapped in a decision possibly made at the age of 15. Research has characterised the period of adolescence as a ‘window of vulnerability’.⁵

Current practices of the UK armed forces for recruiting children capitalise on this ‘window of vulnerability’, and indeed do not meet the criteria for ‘voluntary and informed consent’. Over the past year, details of these practices have been revealed in the media. In June 2018, the Guardian revealed that the Army had been deliberately targeting recruitment advertisements on Facebook at vulnerable 16-year-olds awaiting GCSE results. Furthermore, a briefing document from the Ministry of Defence for Capita, a private company contracted to deliver military recruitment campaigns, referred to the key audience being ‘16 to 24 year olds’ in the lowest three social and economic groups.

Multiple attacks on health and well-being

Adolescence is the ‘period between childhood and adulthood, characterised by rapid development in psychological, social and biological domains’.² Military service during this period has long-lasting and complex effects on health (table 1). As child recruits are more likely than adult recruits to end up in frontline combat roles, they are more likely to experience physical or psychological trauma and to be killed.²

Table 1.

Child health in armed conflict

Mechanism	Effect
Mortality	The fatality rate of frontline combat infantry in Afghanistan was seven times higher than that in the rest of the armed forces9
Illness	Conditions for maintenance of child health deteriorate in war—nutrition, water, safety, sanitation, housing and access to health services. Sustained deficiencies in these areas have been shown to have significant impacts on growth in children and adolescence10
Mental health	Younger military personnel are at a greater risk of mental health disorders than their civilian counterparts: Exposure to combat is a risk factor for PTSD and other mental disorders, particularly among younger personnel and individuals with pre-existing psychosocial vulnerabilities and mental health conditions11 Self-harm and suicides in the UK armed forces are more common among younger personnel and exceed rates for young civilians12 13 Rates of alcohol misuse are considerably higher in the UK armed forces than in the general population. Young age is particularly associated with alcohol misuse in the UK armed forces14 These problems are related to the isolation and enculturation into military life, the trauma of combat, but also to the higher prevalence of preservice vulnerabilities among young recruits to the armed forces
Educational outcomes	In the armed forces, educational underachievement is a marked risk factor for PTSD as well as other common mental disorders, alcohol misuse, aggressive behaviour and violence.15 For instance, one study found a PTSD rate of 8.4% among Iraq War veterans who had joined the armed forces with no GCSE qualifications, compared with 3.3% among those with A levels16

PTSD, post-traumatic stress disorder.

Unjustifiable

In the face of such evidence for harm, why does the UK military continue to recruit 16-year-olds? Is the recruitment of adolescents a responsible piece of public policy? The main justification rests on fears of a ‘recruitment shortfall’: the British Army claims the UK is short of 8200 military personnel, with recruitment down by 24% in 2016–2017 and a greater proportion of staff leaving the military. Be that as it may, given the extensive harms described above, to put recruitment figures above the health and well-being of children and adolescents seems misguided and counterproductive for both the Ministry of Defence as a governmental body and wider society.

The second justification espouses economic and occupational benefits to recruits, many of whom come from disadvantaged backgrounds, arguing that the military offers training, discipline and opportunities to ‘rise up the ranks’. Again, we have seen that it is precisely child recruits from disadvantaged backgrounds who are at highest risk of adverse outcomes in the military. Furthermore, figures from 2017 show that those recruited under the age of 18 constituted 24% of those who voluntarily left the Armed Forces before completing their service—this also increases the likelihood of lower mental health outcomes.^{6 7} As such, the UK should end its practice of recruiting adolescents to the Armed Forces. It would be both more financially sustainable and better for the mental health and social outcomes of military personnel if the Armed Forces instead invested in the training and well-being of serving personnel.

What can clinicians do?

Clinicians occupy positions of voice and power. The Royal College of Paediatrics and Child Health (RCPCH) states that ‘Paediatricians are committed to a policy of advocacy for a healthy lifestyle in children and young people and for the protection of their rights’. To fully realise this goal for this group, then, what can clinicians do?

Earlier this year, Medact submitted evidence to the Defence Select Committee inquiry into the mental health of UK Armed Forces personnel and veterans, focusing on the health outcomes for those recruited as adolescents.⁸ Medact will continue to publish research on this, alongside the scrutinising of past and current recruitment practices aimed at children and minors.

Mental health specialists and paediatricians interested in this issue are invited to feed into Medact’s ongoing research in this area. Paediatricians are encouraged to join the RCPCH Parliamentary Panel for further training around advocacy skills to be able to better represent patient interests. Interested clinicians can find informative resources on these health impacts and policy updates, as well as actions that health professionals can take, on the Medact website.