Intended for healthcare professionals

Letters

Protecting children from armed conflict

BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7167.1249 (Published 31 October 1998) Cite this as: BMJ 1998;317:1249

Children affected by war must not be stigmatised as permanently damaged

  1. Derek Summerfield, Psychiatrist
  1. Medical Foundation for the Care of Victims of Torture, London NW5 3EJ
  2. Royal Manchester Children's Hospital, Manchester M27 1HA
  3. Health Operations Division, International Committee of the Red Cross, 1202 Geneva, Switzerland

    EDITOR— Southall and Abbasi quote Unicef when they state that the psychological consequences of armed conflict on children are so great that they can rarely be repaired.1 Unicef indeed says that “time does not heal trauma,” but there is no sound empirical basis for a generalisation that risks stigmatising whole populations of children affected by war as sick or permanently damaged. Even child survivors of Auschwitz did not turn out like this as a general rule, and there are no published studies of children from non-Western war zones to support such a conlusion.

    Unicef and other agencies need to review such claims and costly interventions based on them; the claims owe more to prevailing sociocultural assumptions in the West than anything else. Over the past 50 years psychological explanations for life events and the medicalisation of distress have grown hugely. Because many people believe, for example, that rape or other criminal violence, childhood abuse, or even persistent bullying at school is an experience that may have lifelong psychological effects it seems unthinkable that war and atrocity should not do this to almost everyone exposed to them. Constructions of “trauma” deployed in the health field are increasingly expansive and undiscriminating.2

    No one wants to play down what children may suffer, or that war may produce clear psychological dysfunction in some (a minority). But it is not to their mental worlds but to their social worlds that survivors direct their attention, and humanitarian agencies should follow suit. The literature of both anthropology and mental health (in the case of mental health, starting with a classic study by Freud and Burlingham3) shows the positive impact of family and community in buffering the short and longer term effects of war. The concept of child trauma is currently fashionable. But it is the social, cultural, and economic rebuilding of worlds shattered by war (including valued institutions such as schools), allied to urgent issues of equity and justice, which will determine the future wellbeing of several million child survivors worldwide.4 For those for whom this does not happen war may indeed mean a life sentence, but this is not trauma.

    References

    Repaying debts takes precedence over health care in many Third World countries

    1. C D Cooper, Senior registrar in paediatrics (j2000c{at}gn.apc.org)
    1. Medical Foundation for the Care of Victims of Torture, London NW5 3EJ
    2. Royal Manchester Children's Hospital, Manchester M27 1HA
    3. Health Operations Division, International Committee of the Red Cross, 1202 Geneva, Switzerland

      EDITOR—Southall and Abbasi's editorial outlining the devastating effects of armed conflict on child health is welcome, as is the global perspective they encourage, but their call for aid budgets to be increased needs qualification.1 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 the structural adjustment programmes of the International Monetary Fund in 1990.2 Maternal mortality in Harare doubled in the two years after this.3 In Uganda, for every pound per person spent on health care £5.50 is spent on debt repayments.4 It is estimated that 21 million children will die in developing countries before the millennium as a direct result of these policies.5

      A rally of 60 000 people, including many medical staff, gathered in Birmingham on 16 May to draw these facts to the attention of the G8 world leaders' summit. There was a cursory response from the political leaders and no change of policy.

      Third World debt continues to have devastating effects on health. If targeted and controlled, aid programmes can be effective, but the crushing cycle of poverty will continue until politicians address the issue of debt in a meaningful way. The BMA can contribute by supporting the call by Jubilee 2000 (a coalition of development agencies) for debt relief and by encouraging its members to sign the petition which is gathering worldwide support; for more information contact Jubilee 2000, PO Box 100, London SE1 7RT (tel 0171 401 9999).

      References

      Are most casualties non-combatants?

      1. David Meddings, Epidemiologist
      1. Medical Foundation for the Care of Victims of Torture, London NW5 3EJ
      2. Royal Manchester Children's Hospital, Manchester M27 1HA
      3. Health Operations Division, International Committee of the Red Cross, 1202 Geneva, Switzerland

        EDITOR—Southall and Abbasi's assertion that civilians account for nine tenths of casualties from recent conflicts is difficult to accept.1 Others making a similar contention provide references either to authors who have made the claim previously or to sources that make the claim without providing any methodology describing how the determination was made.

        The International Committee of the Red Cross helps victims of armed conflict. This help can include surgical care, and a database recording information relating to the committee's surgical activities since 1991 contains data on over 28 000 people, of whom 18 831 have sustained weapons injuries.

        The committee does not ask individuals to declare themselves as combatants or as 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 female; male and aged under 16; or male and aged ≥50.2 Clearly, this figure is a lower bound on the proportion of people with weapons injuries who are probably non-combatants and received care under the auspices of the Red Cross.

        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 merits consideration if one wishes to protect children and other civilians during armed conflict.

        Southall and Abbasi 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.

        Attempts to study the events accompanying armed conflict have inherent limitations. One should approach these as in any other research context, controlling threats to internal and external validity as best one can and drawing conclusions without resorting to overstatement. The data, unfortunately, are bad enough that they speak for themselves.

        References

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