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The recent International Committee of the Red Cross report, Civilians without Protection, makes it clear that the conflict in Iraq is inflicting immense suffering on the civilian population.1 Mental health as an aspect of suffering in war has been receiving increasing attention, with particular concerns centring on children because of their vulnerability and the growing awareness of the potential long-term harm to society through disruption of human attachments, and the development of aggressive patterns of behaviour, which have the potential to aid recruitment to terrorist networks.2,3 There is debate about models of treatment, resources for reconstruction and protection of the innocent.
Iraqi children and adolescents form more than 55% of the Iraqi population (29 million people). Over the last two decades they have experienced high levels of psychological trauma, such as loss of parents due to imprisonment or death, dislocation of families, exposure to violence and conflict, and the witnessing of scenes of carnage; many have suffered religious and political persecution, detention and torture.
Since 2003, rates of direct physical harm and abuse have been high. There is no hard data on child deaths, though Burnham et al. record 26 of the 300 violent deaths in their survey as being children under the age of 14;4 it is therefore likely that many tens of thousands of children have been killed and injured in this conflict. There is concern about an increase in physical violence against children within families. There are also a significant and growing number of orphans for whom no organized services are available.
Many reports indicate that insurgent groups and militias are involving minors, including orphans and children of insurgents, in the fight against the Multi-National Force (MNF) and Iraqi Security Forces (IFS).5
Children have been arrested and detained by the MNF and by the IFS. There are reports that children are held in the same cells as adult detainees and subjected to the same treatment, including torture. Human Rights Watch recorded the case of a juvenile who was beaten with cables and underwent falaqa (beating on the sole of the foot) while being held in the custody of the criminal intelligence service.6
An estimated four million Iraqis—nearly 15% of the total population—have fled their homes, 50% of whom are children. Approximately 1.9 million people have sought refuge inside Iraq, and 2.2 million have crossed the border into neighbouring countries. Amongst those fleeing are doctors, nurses and teachers—a devastating brain-drain that is leaving many Iraqi children without access to quality education and basic health care.7
The impact of all this on the mental health of children and adolescents must be great. A study in Baghdad in 2006 showed that 47% of children reported exposure to a major traumatic event during the previous two years; 14% suffered post-traumatic stress disorder (PTSD). In a second study in Mosul, 30% of adolescents had symptoms of PTSD.8 Other studies have shown that up to 50% of Iraqi children have behavioural problems.
The response to these problems has to take into account the high levels of threat, the different developmental stages of the affected children and the diverse and different cultural values, and requires ongoing debate and development. Key to it all is social stability, especially for the family, and continued education.9 However, an estimated 50% of children living in urban areas no longer go to school because of the security threat. In rural areas the numbers are even higher; in some areas drop-out rates for attendance in 2006-2007 were as high as 70%.10 UNICEF has called for greatly increased support for education and basic services for the two million Iraqi children now displaced and relocated in more stable areas, and has launched an appeal for US$42 million.7
The mental health services, along with other health services, have collapsed, and while security is a crucial consideration, there has been great concern expressed about the failure of promised resources to materialize and the misuse of resources once in Iraq.11 In 2003 the World Bank estimated that $56 billion was required to rebuild Iraq, of which $33 billion was pledged. So far only 56% of the money promised to Iraq in 2003 by the international community has been made available.12 Over the four years since 2003, the UK Department for International Development has donated £107 million for health care in Iraq12 (about 93 pence per capita per annum). Last year Medact reported that despite $1 billion being given to the health system by the US, 25% of this had gone on security and the Iraqi Ministry of Health was estimating that $8 billion was required over the next four years, in addition to operating costs.11
Prevention is an essential medical approach. The protection of the innocents in war has been a key theme of the Geneva Conventions and, along with the UN Convention on the Rights of the Child, provides a legal framework by which child protection can be addressed by state signatories. The International Criminal Court can provide the framework to prosecute parties breaching these conventions, especially the recruitment of children into military and para-military activities. A strengthening of the UN High Commission for Human Rights and the role of the Special Representative for Children in Armed Conflict is required. However, if dominant states are not brought to account for alleged wrongdoings, such as detention and torture of children, then the chance of these laws becoming firmly established is reduced and the protection of children in war is less likely.
The situation in Iraq is an example of the dreadful human cost of war. If wars cannot be prevented then realistic resources need to be made available for post-conflict reconstruction, the laws protecting children need to be strengthened and applied, and the management of the mental health aspects of suffering need to be further developed. Whilst human resilience is an important notion, it is also important to consider the damaging impacts of war not only for the people caught up in it, but for the region and for humanity itself.2
Competing interests None declared.