Safaa Bahjat

Correspondence:
Dr. Safaa' T. Bahjat (Allergologist)
MBChB, MDAID
Kirkuk ,Iraq
Email: dr.safaabahjat@hotmail.com

In the Middle East, children bear disproportionate consequences of armed conflict. The 21st century in Iraq ,Syria, Palestine, Yemen and Lebanon continues to see patterns of children enmeshed in international violence between opposing combatant forces, as victims of terrorist warfare, and, perhaps most tragically of all, as victims of civil wars. Innocent children so often are the victims of high-energy wounding from military ordinance. They sustain high-energy tissue damage and massive burns - injuries that are not commonly seen in civilian populations. Post-traumatic stress disorder remains an undertreated legacy of children who have been trapped in the shot and shell of battle as well as those displaced as refugees.

The stigma of the ugliest economic sanctions and the dirty oil for food program imposed on Iraq will be the companion of the grave for all those who approved that security council resolution, nearly a million Iraqi children died because of it. I recall the sadness of an old friend, an Australian woman when she was watching the news, as she wrote to me later, by the view of the medical staff in Baghdad who were trying to insert an adult urine catheter for a child because of the shortage of catheters.

Economic sanctions is one type of catastrophic disaster that ranks, from the perspective of the child, with other disasters, such as earthquake, famine, cyclone and epidemic pestilence. Children are killed in war by the direct effects of blast, bomb and missile and are injured by burns, gas and rubber bullets. Large numbers die from exposure, disease and starvation. During conflict, in the protracted periods between shelling or hand-to-hand assaults, children live in fear of impending attack. Much has been written about the stress reactions of children trapped in such circumstances, especially of those under missile threat, such as occurred in the Gulf War.

Currently, children experience the daily threat of suicidal car bombings in more than one country. No-one knows how many children are killed and injured by suicidal car bombings in the aftermath of both Iraq invasion and civil war, the same thing is true in the Syrian conflict. The medical consequences of car bombings, as these affect children, are well known. Avulsion of one or both feet or lower limbs, shrapnel fragmentation wounds to the pelvis and abdomen , and blinding in one or both eyes are common. Conductive deafness is almost inevitable. The legacy of legless, partly deaf, partly blind and orphan children is a challenge for preventive medicine and one that the international medical profession - indeed all who care for children - cannot ignore.

'The mind in infancy is, methinks, like the body in
embryo; and receives impressions so forcible, that they
are as hard to be removed by reason, as any mark with
which a child is born. …'

A proportion of those who survive with life and limb intact inevitably carry the scars of war, of natural disaster, or of refugee existence into their lives and sometimes to the next generation.
The few studies of children in the aftermath of war and other catastrophic disasters have documented fear-conditioned responses to the experience of early violence. These include regressive or aggressive behaviour, another long-term legacy of early exposure to the violence of armed conflict. Most adults have had the experience of an unaccustomed food-smell or plant-odour giving one an instant flashback to one's youth. Normally these are pleasurable instant recollections - survivors in the human rhinencephalon of the highly developed 'smell-memories' of lower animals. Children who have survived war also experience these - but the triggers are the smell of burning, of bloody wounds and of high explosives.

The influence of such stress starts from the time of birth. The average birth weight of children and the nutritional indices of those infants who continued to be breastfed were reduced. That was crystal clear in the south and west parts of Iraq like Falloja and Nassyria cities.

Of greater import is the fact that if children are exposed to the maiming and killing of war, they carry into their adult lives a new datum reference point - that violence is the basic relationship that characterizes humankind. There is a danger that the offspring of these child survivors of warfare will, in a quasi-genetic, second- and third-generation transmission, be exposed to influences where violence is more likely to be regarded as acceptable, or even regarded as the normal state of affairs.

One of the most important attributes of childhood is the development of conscience. That is, the acquisition of a sense of higher-order morality and ethics. The development of this sense of what is right and what is wrong, of this sine qua non of supra-animalistic life, depends enormously on the experiences of childhood. It is especially related to experiences in early childhood. Exposure to violence, to cruelty and to the systems of war where the resolution of problems is perforce solved by force during the childhood years is inimical to the development of conscience. One precondition for conscience and the normal development of an evolving ethical and moral sense is 'sensitivity to people who do not belong to one's own narrow circle', as the German writer Christa Wolf espoused in her autobiographical novel A Model Childhood/. War-imposed terror and cruelty, directed against others but observed by the child, determine the norm in the evolving conscience of a growing child. Post-traumatic stress disorder, with its morbidity of personal distress and agony, has been very much a featured disease of the late 20th and 21st centuries. Children are less likely than adults to talk about such episodes or to understand their genesis. Nevertheless, recurring obsessive thoughts of horror, flashbacks and recurring dreams either of stark reality or of symbolic illusion are some of the chronic symptoms of this childhood disorder. Because children do not write, while they are children, about their traumatic experiences, it is easy to overlook the immediate effects of war on them. We catch occasional glimpses of these effects through the eyes of children in such works as Frankenstein in Baghdad or second-hand through the eyes of physicians and paramedical staff who care for such children. The important issue here is to maintain advocacy that combat, especially that enjoined in civil war, brings with it a post-conflict debit, often unanticipated, but one that needs to be marked in red on the balance sheet of both victory and defeat. All with personal experience of civil and guerrilla warfare are familiar with the secondary effects of social disruption on children's lives. In international war, or in civil war situations where there is a breakdown of law and order, exploitation of children in the form of child labour , child and teenage prostitution, child drug dealing and forced military service become accepted as the normal societal state. There is also the abduction of children as we had seen in Iraq either to get ransom if the family was wealthy or for organ trade if they were poor.

Child soldiers, as the term is used today, make up a new class of combatants distinct from those of immature years who have, since the times of ancient Greece, served in uniform as an adjunct to the armies of the past. The child soldier of today reflects a triad of anarchic civil war, high technology and lightweight weaponry, and drug or alcohol addiction. Child soldiers have no socialization of any higher ethic other than that of violent exploitation to satisfy the dictates of short-term gratification of instinctual drives. The tragic and new syndrome of child soldiering most often affects boys between the ages of 8 and 18 years; they are bonded into an armed group of peers, almost always orphans, drug or alcohol addicted, amoral, merciless and dangerous, illiterate, armed with an automatic or semiautomatic weapon and a knife; they rape, steal and pillage without compunction or remorse. Their targets are never strategic or tactical, but personal. They are opportunistic in their choice of victims, and do not discriminate between male or female, young or old, civilians or soldiers. The modus operandi of killing is often brutal, even involving mutilation. These child soldiers have become a phenomenon newly encountered in the 20th century and accruing with a tragic currency in the new millennium. The theme of child soldiering is a pragmatic and inescapable contemporary issue for what is now the global village of all humankind. Child soldiers are vulnerable to three profound sequelae in their adult lives. The first of these is that the desocialization and dehumanization of a young adolescent's mind becomes self-perpetuating. The excitement of interpersonal physical conflict, of combat, of dominance and of sexual violence entraps such victims. Second, the 'lost childhood' of these victims means that schooling and subsequent rehabilitation are very difficult. Third, although as yet there is no published work on the long term sequelae of 'life and childhood in combat ranks', all who work with children and adolescents are aware of the inescapability of post-traumatic stress disorder. In particular, someone enmeshed throughout their formative years in society-induced psychopathy is very difficult to rehabilitate. The responses of young adolescents to violence and disaster cause profound changes in their attitudes towards life and their future. Adolescents exposed to trauma demonstrate increased risk-taking behaviour. Often, in the pre-recruitment phase when a child or young adolescent is particularly vulnerable to enlistment as a child soldier, he or she has already lost both parents, some or all of their siblings and their extended family. The situation can be compounded by the fact that when parents or other close relatives are lost in massacres, landmine or bomb blasts, or in epidemics, the normal rituals of closure do not occur.

Young adolescents enmeshed in civil wars are constantly exposed to threats on their own lives. They have been shown to be associated with perhaps the highest risk of psychiatric morbidity. Those who are themselves injured by violence or disaster are at highest risk. Exposure to dead bodies and mutilated victims increases the potential for adverse psychiatric sequelae. Of the many different types of stressor, the most powerful predictor of post-traumatic stress disorder is physical violence itself.

Children and young adolescents are traumatized as child soldiers. As they are the perpetrators of violence, this trauma might simply be a chronological sequel to their entire lifetime experience, they themselves having been traumatized as preschool children. Preschool children exposed to violent trauma, even in the civilian sphere, are known to exhibit behavioural re-enactments of such trauma in their play and story-telling. The anarchic milieu in which child soldiers operate provides a gruesome and tragic opportunity for them to live out their fantasies of revenge in real life. Violent behaviour by male adolescents is highly correlated with prior personal violent acclimatization, even in otherwise stable, civilian, developed nations where violence, victimization and later physical assault perpetration are not generally condoned. Adolescent males, in particular, are likely to re-enact their own experience of violence victimization by perpetrating similar forms of violence on others. There are no reports of quantitative studies of violence exposure of child soldiers; not surprisingly, as almost all child soldiers are illiterate. 'A key issue is what to do with thousands of young men who have, over two decades of conflict, learned little more than how to pull a trigger. Some adolescents exposed to violent trauma respond by developing the certainty that life will be short and that a shortened future with an enhanced sense of fragility is their lot.

Under such circumstances, pathologically socialized young adolescents join the flight into hedonism. In the current civil war in Syria , many of refugee camps have witnessed the death of their children or of a child in their care. Many reports show that someone in the family has attempted suicide. These stresses on children do not apply only to the vanquished. Australian children, the offspring of Vietnam veterans, have a suicide rate threefold that of the general community; and there is every indication that the high numbers of suicides among veterans' children will continue, as they pass through ages for even higher risk of suicide. In this context, all would agree with Benjamin Franklin that 'There never was a good war or a bad peace'.

We can do much to ensure that the children of a future world will have better opportunities for a normal and enriched childhood, irrespective of the accident of their place of birth.