Wars and Children.

“Every war is a war against children” said Eglantyne Jebb, founder of the “Save the Children“ organization, 100 years ago just at the end of World War I.[1] Undoubtedly, wars affect the whole population, but children have unique vulnerability during armed conflicts. Today, conflicts are not only between states and soldiers, but also civilian groups are ever more affected. Nearly 90% of deaths from wars in the first decade of the 21st century included civilians, a significant number of whom were children.[2,3] During many conflicts children are targeted indiscriminately or even intentionally. In 2017 more than 40 active conflicts ensued around the globe and approximately 420 million children were living in conflict zones.[1,4] This means that 1 in nearly every 5 children worldwide faces danger of death and hardships of war.

To better monitor the pediatric victims, United Nations Security Council has identified six grave violations in times of war and evaluated the numbers of attacks and affected children between 2005 and 2020.[5]

Killing and maiming of children (more than 104.000, two-thirds of these since 2014)

Recruitment or use of children in armed forces and armed groups (more than 93.000)

Attacks on schools or hospitals (13,900 incidents of attacks)

Rape or other grave sexual violence (at least 14.000 children, 97% girls)

Abduction of children (at least 25.700)

Denial of humanitarian access for children (14,900 incidents of denial of humanitarian access for children).

These are official numbers for some direct effects of armed conflicts on children and represented only the tip of the iceberg. Mortality and morbidity indirectly related to conflicts is more complex to estimate than direct counts. During wars, many factors, including inadequate living conditions; lack of electricity, tap water and food; breakdown of health services; disruption of immunization programs; unavailability of medicines; loss of parents/caregivers and separation from the family may affect health of children, although systematic evidence is scarce. Existing evidence shows the relationship between conflicts and malnutrition, physical injuries, infectious diseases and poor mental health.[6] The results of a study carried out across 35 African countries suggest that from 1995 to 2015, infants exposed to armed conflict in the first year of life suffer from 7·7% higher risk of dying before reaching age 1 year than their counterparts living in a region without armed conflict.[7] This corresponded with 3·1–3·5 million infants (and 4·9–5·5 million children younger than 5 years) whose deaths were related to armed conflict over this period in Africa. If these statistics are applied to 64 countries around the world where conflict events continue, more than 10 million deaths in children younger than 5 years can be attributed to conflicts between 1995 and 2015 globally.[6]

In addition to the short -and medium- term negative effects of wars on children’s’ health, exposure to armed conflict has social and psychological repercussions that continue many years after the termination of hostilities.‍ Among adolescents, post-traumatic stress disorder and increased rates of substance abuse are reported.[8] Lack of education during wars may block to acquire a profession and affect the future quality of life.

Chronically ill children represent a special group, who suffer dramatically from wars.[9] They need many types of treatment facilities, equipment, and drugs to survive. In times of armed conflicts destruction of healthcare infrastructure, shortage of healthcare personnel and medical material are life-threatening factors for these patients.

Wars force civilians to flee their homes and lead to displacement of populations. Displacement may be within the borders of the country (internally displaced people) or across international boundaries (refugees and asylum seekers). According to the data of the United Nations Refugee Agency, at the end of 2020, 82.4 million forcibly displaced people exist around the world; 48.0 million of whom are internally displaced people, 4.1 million asylum seekers and 30.3 million refugees.[10] Almost half of the refugee population are children, and nearly one million were born during displacement between 2018 and 2020. Refugee children encounter many problems during travel, and at destination. 85% of refugees worldwide are hosted by developing countries. Children who are forcibly displaced have even more limited access to basic needs, such as sanitation material, potable water, adequate nutrition, and education as compared to local population.[11] They are less likely to receive vaccinations, which triggers outbreaks of vaccine preventable diseases. Refugee children have difficulties to reach health care facilities. Families are unaware of the health services and have financial problems; language barrier is another critical problem.[12]

During the last two decades armed conflicts took place mostly in developing countries in Middle East, Africa, Asia and Latin America. Although Iraq, Afghanistan and Syria conflicts are well known because of political intention, many others are forgotten, or ignored. Efforts of some humanitarian organizations [United Nations Children's Fund (UNICEF), Save the Children…] to improve condition of the children during conflicts were far from meeting the demand; consequently, children in conflicts went unrecognized.

Following invasion of Ukraine on February 24, 2022, European countries and several pediatric medical associations were alerted with potential risks of war towards the children. This unfortunate experience may be a good opportunity to draw attention of medical community and humanitarian organizations to make effective preparations for saving children during armed conflicts.