Protecting children from armed conflict
BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7144.1549 (Published 23 May 1998) Cite this as: BMJ 1998;316:1549
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Dear Sir,
Professor Southall`s leading article, (1), outlining the devastating effects on child health from armed conflict is welcomed, as is the global prospective he encourages. However his call for aid budgets to be increased needs qualification. Repayment of debt by impoverished countries to the industrialised nations is greater than aid payments by a factor of three to one. Health budgets are being restricted in order to make these payments, under the direction of the International Monetary Fund. In Zimbabwe for example, health spending per head has fallen by a third since the introduction of I.M.F. structural adjustment programmes in 1990 (2). Maternal mortality in Harare doubled in the two years following this (3). In Uganda, for every pound per person spent on healthcare, £5.50 is spent on debt repayments (4). It is estimated that 21 million children will die in developing countries before the millenium as a direct result of these policies (5).
A huge rally of 60,000 people, including many medical staff, gathered in Birmingham on May 16th to draw these facts to the attention of the G8 World Leaders` Summit, ( BMJ News May 23rd). There was a cursory response from the political leaders and no change of policy.
`Third World` debt continues to have devastating effects on health. Whilst aid programmes if targeted and controlled can be very effective, the crushing cycle of poverty will continue until the issue of debt is addressed in a meaningful way by politicians. The B.M.A. can contribute by supporting the call by Jubilee 2000, a coalition of development agencies, for debt relief, and by encouraging it`s members to sign the petition which is gathering worldwide support.
Yours sincerely,
Dr. C.D.Cooper, M.B.Ch.B., M.R.C.P., D.T.M.&H.
Senior Registrar in Paediatrics, Royal Manchester Children`s Hospital.
1. Southall D, Abbasi K, Protecting children from armed conflict. BMJ 1998 ; 316 : 1549 - 1551. ( 23rd May)
2. Oxfam Policy Document, A Case for Reform, Oxfam Publications 1995
3.Chisivo M, Government spending on social services and the impact of structural adjustment in Zimbabwe, UNICEF document 1993
4. Multilateral debt : The human costs. Oxfam International Position Paper 1996
5. Human Development Report, United Nations Development Programme, 1997
For more information, contact Jubilee 2000. P.O.Box 100, London SE1 7RT, Tel. 0171 401 9999
e-mail : j2000c@gn.apc.org
Competing interests: No competing interests
EDITOR-In their editorial Southall et al highlight several important issues concerning children and armed conflict.1 However, their assertion that civilians account for 90% of casualties from recent conflicts is difficult to accept.
Others making a similar contention either provide references to authors who have made the claim previously, or sources that make the claim without providing any methodology describing how the determination was made.
The International Committee of the Red Cross (ICRC) assists victims of armed conflict. This assistance can include surgical care, and a database recording information relating to ICRC's surgical activities was begun in 1991. The database presently contains data on over 28 000 people, of whom 18 831 have sustained weapons injuries.
ICRC does not ask individuals to declare themselves as combatants or non-combatants; sex and age are the only criteria by which one might estimate the proportion of non-combatant casualties from these data. An analysis of the first 17 086 people admitted for weapons injuries reported that 35% were either female, males less than 16, or males 50 and older.2 Clearly, this figure is a lower bound on the proportion of weapons injured who are probably non-combatants and who received care under the auspices of the ICRC.
More important than the actual proportion of civilian casualties is the fact that this figure has been rising.3 In turn, this rise is associated with an increased incidence of low intensity conflict, and an increasingly blurred border between insurgency and criminality.4 Complex factors and interests account for this, including the fundamental weakness of many states, and the ease with which light weapons circulate throughout large parts of the world.5 It is the interplay of these determinants that merit consideration if one wishes to protect children and other civilians during armed conflict.
Southall et al rightly point out that advocacy is a powerful tool available to the profession. But advocacy should be linked to credibility, and erroneous or exaggerated data can be used to undermine the validity of important messages and the trustworthiness of those who would bring them to the attention of the international community.
There are inherent limitations in trying to study the events accompanying armed conflict. However, one should approach these as in any other research context, controlling threats to internal and external validity as best one can, and drawing appropriate conclusions without resorting to overstatement. The data, unfortunately, are bad enough that they speak for themselves.
David Meddings Epidemiologist
Health Operations Division
International Committee of the Red Cross
19 ave de la Paix, 1202 Geneva, Switzerland
1. Southall DP, Abbasi K. Protecting children from armed conflict. BMJ 1998;316:1549-1550.
2. Coupland RM. The effects of weapons: Defining superfluous injury and unnecessary suffering. Medicine and Global Survival 1996;3:1-6.
3. Garfield RM, Neugut AI. Epidemiologic analysis of warfare. A historical review. JAMA 1991;266:688-692.
4. Meddings DR. Weapons injuries during and after periods of conflict: retrospective analysis. BMJ 1997;315:1417-1420.
5. Smith C. Light weapons and the international arms trade. In: Small arms management and peacekeeping in Southern Africa. Geneva: United Nations Institute for Disarmament Research, 1996;1-59.
Competing interests: No competing interests
Re: Armed conflict and civilian casualties
We are grateful for the information provided by Dr Meddings, from data of the International Committee of the Red Cross, and agree fully that the most important information is that the actual proportion of civilian casualties during armed conflict is rising.
As to his criticism of our facts, we obtained our information that 90% of deaths during armed conflict are of civilians, from what we considered to be reliable sources. Firstly, the Graca Michel report on armed conflict in children (1), which states: "civilian fatalities in wartime have climbed from 5% at the turn of the century to more than 90% in the wars of the 1990s." Secondly, the "State of the World's Children" report by UNICEF in 1996 (2), notes that the proportion of civilian victims of armed conflict "by the end of the 1980s was almost 90%," as quoted from the Department of Peace and Conflict Research (3).
We agree that for advocacy to be effective, the data must be accurate and not exaggerated, but we were limited in the number of references we could quote, and felt that these two pieces of information were likely to be accurate. If he remains sceptical, then perhaps Dr Meddings should take this issue up with UNICEF.
In his response, Dr Coooper explores the issue of so-called "third-world debt" and we support his sentiments and those of Jubilee 2000.
References
1. Impact of Armed Conflict on Children: report of Graca Machel, expert of the Secretary of the UN. UNICEF August 1996;A/51/306.
2. State of the World's Children. UNICEF 1996. Oxford University Press.
3. Ahlstrom Christer. Casualties of conflict: report for the world campaign for the protection of victims of war. Department of Peace and Conflict Research. Uppsala 1991;8,19
Competing interests: No competing interests