Mitigating Armed Conflict Casualties in Children

Similar to previous reports,^1–12 the latest annual United Nations (UN) Report on Children and Armed Conflict identified 10 173 child casualties and 4019 children killed in armed conflicts the preceding year.⁶ Most of these children were victims of “internationalized” conflicts, defined as internal conflicts in which ≥1 third party governments are involved with combat personnel.¹³ Five such protracted conflicts involve the United States and allied armies (Afghanistan, Syria, Yemen, Somalia, and Mali). These account for 69% of total reported child casualties and 64% of children killed. We present examples of how children continue to be harmed in armed conflicts as well as practical suggestions for how pediatricians can help reduce the impact of armed conflicts on children.

Children are inadvertently harmed in conflicts. However, many civilians, including children, are injured or killed because of policies and compromises made by military operation planners. For example, the Islamic State of Iraq and Syria used civilians as human shields in urban areas. To expedite the operation to eliminate the Islamic State of Iraq and Syria in Iraq and Syria while limiting US ground troops, US government policy makers increased the “non-combatant casualty value,” the number of civilians allowed to be killed per air strike.¹⁴ By 2018 at least 1139 civilians, including children, were killed in that operation over a 4-year period; many died as buildings collapsed from airstrikes, undoubtedly an underestimation because on-site investigations were not conducted.¹⁴

Indiscriminate use of arms, lack of accountability, and deliberate targeting of civilian populated areas increase risks to children. In 2015, among 1953 casualties in children reported by the UN in Yemen, 60% were due to airstrikes² with armament manufactured by the United States, United Kingdom, and other allies. Yet, the US government curtailed training in precision targeting for coalition pilots flying over Yemen.¹⁵ Subsequently, a school bus with >40 children was bombed.¹⁵ In 2019, 12% of the 1447 child casualties in Yemen were from airstrikes.⁶ In 2019, Syrian and Russian forces targeted civilian populations, with air attacks on medical and other civilian facilities over an area the size of Luxembourg in Idlib, terrorizing civilians. Among the 1454 child casualties in Syria, 35% were from airstrikes.⁶ In addition, according to the UN, nonstate actors in Yemen and Syria, working with outside states, restricted access to humanitarian care and demanded payments from fleeing civilians, among other human right abuses.^1–12

Political barriers and a lack of adequate medical care and evacuation resources result in further harm. In a review of pediatric combat trauma care, it was observed that >80% of children died at the scene of the attack or during transportation to a health facility.¹⁴ Children are more likely to incur head trauma, compared with adults, and often suffer from complex injuries (face, eyes, trunk, vasculature, extremities, or burns), requiring prolonged admissions, repeated surgeries, and intensive and expert multidisciplinary care in secure, well-equipped medical facilities.¹⁶ Recent studies were conducted in countries neighboring conflict zones, such as Turkey, or in military trauma units.¹⁶

In contrast, nonmilitary data on combat trauma care from inside conflict areas are limited. In a recent study, researchers examined hospital conditions during urban sieges in Syria.¹⁷ Personnel reported shortages in medicine, equipment, electricity, and lack of staff (including neurosurgeons), often working in underground facilities to avoid airstrikes.¹⁷ Although difficult to collect, information related to access to quality tertiary and quaternary care inside and/or across borders is necessary to optimize the care of these children.

As the world’s largest purveyor of arms, since the year 2002, the United States has exported between $15 and $75 billion in arms per year, representing up to 4% to 5% of its total annual exports.¹⁸ Economic interests often drive these sales.¹⁸ Although the US government is legally required to prevent arms sales to states that use them indiscriminately, in an analysis, researchers found no correlation between the size of arms sales and human rights abuses or bloody civil wars committed by purchasing states.¹⁸ A fraction of military expenditures in Yemen could cover its emergency humanitarian needs, yet these remain unmet.

• Copyright © 2021 by the American Academy of Pediatrics