Child health in armed conflict: Time to rethink

By: Anthony B. Zwi, Natalie J. Grove, Paul Kelly, Michelle Gayer, Pilar Ramos-Jimenez, Johannes Sommerfeld

The health of children is compromised by armed conflict, complex political emergencies, political upheaval, and forced migration. Children and young people comprise a significant proportion of the population in many countries, and often predominate in refugee or internally displaced settings. These environments expose them to risky situations over which they have limited control. An international symposium in Manila drew attention to these issues. Debate  in The Lancet has highlighted the tremendous challenges  of  achieving  the  Millennium  Development Goals  (MDGs),  of  applying  best  practice  in  child-health  interventions,  and  of  assuring  children’s  rights and  voices. Conflict  and  instability  are  significant impediments to achieving the MDGs: in many countries they  have  reversed  earlier  gains  from  childhood  interventions and undermine  livelihoods,  leading to greater poverty and adverse health. Addressing this challenge to child health is urgent.

Children  under  5  years  of  age  have  the  highest mortality  rates  in  conflict-affected  settings. In some situations,  when  childhood  interventions  have  been disrupted  for  periods,  older  children  are  similarly affected.  Diarrhoeal diseases, acute respiratory infections, measles, malaria, and severe malnutrition are the most common causes of death in the early phases of conflict-related emergencies. In addition, outbreaks of other infectious diseases such as pertussis, typhoid, and meningococcal meningitis, can contribute substantially to childhood morbidity and mortality. Little  is  known about  the  effect  on  children  of  chronic  conditions (e.g.,  tuberculosis), or of neglected diseases  (e.g.,  visceral leishmaniasis, African trypanosomiasis) in such settings.

Traditionally,  we  approach  health  problems  through emergency  responses,  ad-hoc  medical  services,  and vertical  disease-specific  programmes,  often  targeted,  on  those  aged  under  5  years.  Although  these programmes  are  successful  in  decreasing  mortality  in camp settings, more comprehensive programmes, such as  the  Integrated  Management  of  Childhood  Illness, have potential for greater impact and sustainability but are rarely implemented fully.

The  disruption  and  displacement  of  families  and communities  during  armed  conflict  often  results  in children  adopting  new  roles.  They may  take  on more responsibility  in  seeking  health  care  for  themselves, or  as  carers  for  others.  Girls in their early teens may themselves be mothers.  Children who were  previously at school, or had been at home or working in the fields, might  need  to  find  paid work  taking  them  away  from family  for  long  periods.  Within the home, children might be more responsible for obtaining and preparing food, overseeing hygiene and collecting water, washing younger children, and collecting firewood, most of which may be done unsupervised and often in situations which put them at risk.

In  Nepal,  the  Maoist  insurgency  and  resultant instability has exposed children to risks of HIV/AIDS and other  infectious  diseases,  trafficking,  and  psychosocial stressors. An increasing number of children are homeless and unaccompanied, yet we know little about them, including whether, or how, they access services.

In northern Uganda, children leave their villages at nightfall and head to nearby towns to seek safety from abduction and violence. They make decisions affecting health  every  day:  where  and  what  to  eat,  where  to sleep,  and  in what  circumstances  they  can  find  safety. They decide what to do if their brother or sister has a fever.  They  decide  which  health-related  resources  to  use:  traditional  healer,  clinic  nurse,  non-governmental organisation, or government  clinic. They decide whom to talk to or be with; they decide whom to trust.

Technical  interventions  exist  for  dealing  with  almost  all  childhood  illnesses  in  conflict  settings;  these  are  particularly  attuned  to  delivery  in  refugee  camp settings. Public-health  practice  typically  adopts  top-down  control  strategies  for  infectious  disease,  seeking to  get  interventions  underway  quickly.  We  may  not have  the  time  or  the  skills  to  find  out  what  is  already being done or what is working, and what strategies have been developed at a household or  community  level. We adopt technical solutions driven by health professionals.  Although  such  solutions  require  active  participation by  the  community,  insufficient  attention  is  given  to how  health  programmes  interface with,  or  engage,  the community. We typically do not elicit perspectives on service acceptability, accessibility, or responsiveness. Little emphasis is placed on understanding the circumstances in which community members will trust health services and service providers, or how and why distrust lingers in fractured communities.

Public-health practice prides itself on being consultative and participatory.  Health  promotion,  prevention  and control of  infectious disease, and epidemic preparedness  and  response  depend  on  extensive  community  participation  and  acceptance,  and  on  understanding  how people react to threats to their health. Appreciating and being  responsive  to  the  cultures,  beliefs,  and  practices of  community members  underpin  the  effectiveness  of public-health  interventions,  but  are  often  neglected  in emergencies. Even where consultation is present, health promotion  and  information  sessions  are  structured around  the  needs  of mothers,  not  those  of  the many children  also  affected.  In  being  protective  and  seeking to  shelter  children  and  young  people,  we  deny  them the opportunity to shape the nature and form of health services  and  health  promotion  activities  in  their  own communities.

Despite  substantial  exposures  and  vulnerabilities, children often  exhibit  strength  and  resilience;  they may actively  respond  to  threats  to  their  health.  They take action to shape their environment. Do we talk with them? Do we hear their experiences and insights? Do we know how they make choices?  The answer, in most cases, is “no”.

Debate in The Lancet has amplified the need to hear their voices and learn. Other disciplines are developing models for engaging with children in vulnerable situations. These approaches differ greatly from more conventional practice,  which  relies  on  adults,  usually  parents  and teachers,  to  convey  children’s  perspectives.  Innovative approaches  show  that  children,  if  appropriately  facilitated,  can  share  important  insights  into their  lives and their  environment,  and  that  such  insights  may  differ substantially  from  those  of  adults.  In  East  Timor  at present,  better  understanding  of  the  perceptions  and perspectives  of  children  and  young  people  should  help shape future services and programmes.

Public-health practice must take seriously the right of children to participate in health decisions that affect them and in research that seeks to benefit them. A first step is to engage researchers in education, anthropology, and the social sciences with experience of undertaking child-centred research and evaluations. We should seek answers to questions such as which children are most affected by conflict and displacement? How do experiences differ by age, gender, and social class? What health risks do children perceive and how do they respond? Are these responses health-promoting or health-threatening?  What  more do  we  learn  from  directly  engaging  and  talking  with children.

We  need,  simultaneously,  to  attend  to  the  important ethical issues raised such as ensuring that children are not pressured to participate, or that advice on  issues that are particularly  sensitive  is  followed  by  enquiry  in  settings where privacy and confidentiality can be better achieved. Consideration and negotiation around offering some tangible benefits for participants is central.

Taking  forward  this work will  challenge  assumptions about  children’s  roles,  responsibilities,  skills,  and competencies  as  they  relate  to  health  research  and the  promotion,  prevention,  and  treatment  of  health problems.  Inviting  children’s  genuine  participation  in health  research,  including  providing  opportunities  to act  as  co-investigators  and  to  help  shape  the  research agenda,  involves a shift  in power. We must be prepared to  listen  to  and  be  led  by  young  people—to  hear  the unexpected  and most  importantly  to  act  on what we find.  This investment is challenging but ultimately worthwhile. It will examine risks to children’s health and reveal the resilience and resourcefulness that children and young people show in the face of adversity.

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