Intended for healthcare professionals

News Roundup [abridged Versions Appear In The Paper Journal]

WHO takes up issue of child abuse

BMJ 2005; 331 doi: (Published 14 July 2005) Cite this as: BMJ 2005;331:129
  1. Sophie Arie
  1. Ljubljana

    In efforts to stop violence against children, the World Health Organization is launching a campaign in which the health sector around the world will play a role. According to WHO, every year across Europe and Central Asia, at least 1300 children die after being beaten or otherwise mistreated by their parents, teachers, or carers. Other deaths are misreported as suicides or accidents, meaning the true figure could be much higher.

    For each death, there are also many babies and children in daily misery at the hands of their parents, teachers, or carers. And yet, for now, the problem is little known or understood in many countries across Europe because of social acceptance, taboos, and children's fear of coming forward, which leads to a lack of evidence.

    Since 2002, WHO has been arguing that violence is a predictable and preventable health problem. But the overwhelming majority of health centres and many family doctors still see child abuse as mainly the concern of the police and social services.

    “What we need is a change of mindset,” said Roberto Bertollini, chief of WHO's environment and health programme for Europe. “The public health approach is a new way of looking at this problem. Evidence is crucial if you want to know what is below the tip of the iceberg—even in well off societies. Public health services are the ones who can gather that evidence.”

    Although police investigate criminals, Dr Bertollini said that health professionals are best placed to gather vital evidence of the harm that adults inflict on their small victims. Standardised procedures must be established internationally to register deaths and injuries. “Health professionals are in many ways on the front line of this problem,” said Dr Bertollini. “They are the antennae. Paediatricians and family doctors could be in a privileged position to identify risks. But they are not doing this systematically.”

    Even in wealthy countries, such as the United Kingdom, only 30% of referrals to child protection services come from the health sector, according to Kevin Browne a consultant to WHO based at Birmingham University.

    In former soviet states and the Caucasus, the situation is much worse. Recent research has shown that medical services could provide a net to catch more cases, given the right guidelines to do so. In Russia, medical staff were given a simple algorithm for identifying child abuse, and the number of cases referred from the health sector to social services jumped from 17% to 50%. More tests are underway at an emergency department in Birmingham.

    “If a child appears in an accident and emergency unit with a scalded leg but no splash marks, the vast majority of medical staff in developing countries would not think to act on their suspicions,” said Professor Browne. “They would just treat the injury.”

    Even once domestic violence is identified, children are not always given the right support once rescued from their violent parents. Across Europe and Central Asia, 23 500 children younger than 3 years are in institutions. Most are in the Czech Republic and in Belgium. Only Slovenia, Iceland, the United Kingdom, and Norway have banned institutional care for children this young.

    Earlier this month, at a meeting of representatives of 52 European and Central Asian countries in the Slovenian capital Ljubljana, WHO, Unicef, and child protection organisations took the latest step towards a global project to end violence against children.

    Their consultation, and eight other such meetings in the rest of the world's regions, will feed into a United Nations' report due out next year. The report will be the first time that the UN has officially called for the world to stop ignoring this problem.

    “In many countries, cats and dogs have more rights than children,” says Paolo Sergio Pinheiro, a Brazilian lawyer and child rights expert coordinating the UN report. “We cannot wait another generation to change policy on this.”

    “I don't think the human rights approach is sufficient,” Dr Pinheiro said. “We ought to consider this kind of violence as a contemporary epidemic. Certain ways of evaluating that epidemic come from the public health sector.”

    This October, WHO will pass a resolution to recognise violence as public health issue. The top priority of the UN report is to call for a global ban on corporal punishment, still permitted in the home in most countries, including Britain and France.

    According to the WHO, identifying the signs of abuse should be made a standard part of the training of all medical professionals. And systems should be put in place to help doctors and nurses refer suspect cases to social services. Ultimately international norms should make governments, not just individuals, responsible for the way their children are treated.

    Existing figures show that 40% of children abused are younger than 5 years old and where registers are kept, children younger than 1 year are the most commonly mistreated.

    According to a Unicef poll of 15 000 children in Europe and Central Asia, 60% are subjected to violence in the home. The chances of a child in Central Asia being abused are three times higher than that of a child in Western Europe.

    But experts emphasise that wealthy nations still fail the children in their midst, in part because of growing immigrant communities with differing cultural attitudes to children. Countries, such as Britain, Germany, and France, still see at least two children die because of abuse each week.

    Susan Bissell, a researcher at Unicef's Innocenti Research Centre in Florence, explained that the failure of systems in countries such as Romania and Uzbekistan has a knock on effect for Western European countries.

    “Women and children seek alternative lives and livelihoods when facing these problems,” Dr Bissell said. All too often, such victims join the masses of illegal immigrants who fall pray to sexual exploiters and traffickers in their effort to reach Western Europe. Setting international standards on violence against children would make governments accountable and increase peer pressure on the countries with the worst records of violence.

    Ultimately, as long as violence against children is not tackled more effectively, even in wealthy Western countries, states will be picking up the pieces at huge cost during the victims' adult lives. Studies show that people who have been abused as children have up to a 12% increase in depression, anxiety, alcoholism, suicide attempts, post-traumatic stress disorders, and obesity. People exposed to violence as children are likely to become violent adults. “The expense of dealing with the effects of child abuse are enormous,” said Dr Pinheiro.

    The most recent calculations show that child abuse costs the United States $94bn (£53bn; £78bn) a year in immediate medical costs, lost earnings, and tax revenue due to premature death, welfare services, foster care, preventive services, and adult criminality. “It's impossible to work out the price of humiliating children in terms of psychological counseling later in their lives,” Dr Pinheiro added. “But it's clear that if you put resources into protecting children in the long run you save money.”

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