Child Health in Syria: Recognising the Lasting Effects of Warfare on Health Delan Devakumar1*, Marion Birch1, Leonard S

Devakumar et al. Conflict and Health (2015) 9:34 DOI 10.1186/s13031-015-0061-6 REVIEW Open Access Child health in Syria: recognising the lasting effects of warfare on health Delan Devakumar1*, Marion Birch1, Leonard S. Rubenstein2, David Osrin1, Egbert Sondorp3 and Jonathan C. K. Wells4 Abstract The war in Syria, now in its fourth year, is one of the bloodiest in recent times. The legacy of war includes damage to the health of children that can last for decades and affect future generations. In this article we discuss the effects of the war on Syria’s children, highlighting the less documented longer-term effects. In addition to their present suffering, these children, and their own children, are likely to face further challenges as a result of the current conflict. This is essential to understand both for effective interventions and for ethical reasons. Keywords: War, Conflict, Children, Health, Syria Introduction Review Civilian populations are increasingly exposed to con- Immediate effects on child health temporary conflicts. That children are amongst the Numerous violations of child rights have been reported worst affected by war is widely known, but the full by the United Nations in Syria. Data from August 2013 extent of their suffering is still not clearly understood. showed that approximately 11,500 children had been This article discusses the effects of the war in Syria killed, with “exponential increases in killing and maiming” on the health of children, with a focus on the less over the previous year [2, 3]. By May 2015 it was esti- documented longer-term health effects. mated that 5.6 million children were in need of assistance The Syrian war is one of the bloodiest in recent times, [4]. As of August 2015, 7.6 million Syrians (approximately with no end in sight and has been described by the half of whom were children) were internally displaced and United Nations High Commissioner for Refugees as the a further 2.1 million children were refugees in nearby “worst humanitarian crisis of our time” [1]. It began in countries [4–6]. January 2011 as a civil uprising on the back of the ‘Arab In addition to death and displacement, the immediate Spring’ movements throughout the Middle-East and costs of war are numerous and include injuries, in- North Africa. The government responded to pro- creases in food insecurity (potentially leading to malnu- democracy demonstrators with violence, a flashpoint trition) and communicable diseases in poorly equipped which ultimately led to armed opposition. A civil war and crowded camps for internally displaced persons and between the Syrian government and opposition groups, refugees. An assessment from 2013 highlighted the level each with their own supporters, ensued. The conflict has of food insecurity, [7] but data quantifying the preva- since evolved into a larger, more complex war, merging lence of malnutrition are generally lacking. Some studies with other regional conflicts involving the Islamic State have assessed nutritional status in refugee camps. A sur- and multiple factions across several countries. vey from a camp in Jordan showed a higher prevalence of anaemia in the occupants than in the host population (48 % (95 % CI 42, 55 %) compared to 26 % (95 % CI 21, 31 %)), although the rates of wasting were no different [8]. In refugee camps in Lebanon, an increase in global * Correspondence: [email protected] acute malnutrition (GAM) was shown between 2012 and 1Institute for Global Health, University College London, 30 Guilford St, 2013 from 4 % (95 % CI 3, 7 %) to 6 % (95 % CI 5, 7 %) London WC1N 1EH, UK in children aged 6–29 months; although this was a non- Full list of author information is available at the end of the article © 2015 Devakumar et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Devakumar et al. Conflict and Health (2015) 9:34 Page 2 of 4 significant increase, under the World Health Organization nightmares, bedwetting and changes of behaviour (ag- (WHO) classification of GAM, the nutritional status of gressiveness or being withdrawn). One study of children in the Syrian camp population is considered “poor” (GAM Lebanon for example, showed an unusually high preva- between 5 and 10 %) [9]. lence of PTSD of 76 % [21]. Children are affected through direct attacks (some- In 2013, 2,000,000 children were estimated to be under- times even deliberate homicide or execution), as victims nourished in both macro- and micronutrients in Syria, of “collateral” damage (for example, indiscriminate use [22] which in early life alters growth trajectories, propagat- of aerial barrel bombs in densely populated cities such ing effects over the life-course and affecting adult stature, as Aleppo), and as a result of the systematic breakdown risk of illness and potential earning capacity [23]. of societal structures [10]. Approximately 1,000,000 Syrian Societal changes can also be long-lasting. Breakdown children are currently living under siege or in areas hard of community structure results in children taking on to reach due to violence [6]. Whereas Syria’spublichealth roles reserved for adults at the expense of education and indicators were improving before the war, and the country loss of future earnings, [24–26] an extreme example be- was experiencing an increase in life expectancy and chan- ing their use as child soldiers [27, 28]. War can provoke ging disease patterns from communicable to non- family breakdown through death and displacement, and communicable diseases, its health system has now col- can also change the roles of remaining family members lapsed [11, 12]. In 2014 the WHO reported that nearly [29]. Half of school-age children within Syria and two- three-quarters of hospitals and one-third of primary thirds of Syrian refugee children are not in school [30]. health care facilities were unable to function, and that It is estimated that this will cost the country up to 5.4 % hospitals (and also schools) were being used as military of its Gross Domestic Product if in the long term the 2.8 bases, exposing them to opposition attack [10, 13]. Water children this represents never return to school [31]. This supplies have been targeted deliberately; those of Aleppo, is compounded by an exodus of the educated population for example, failed after the Al-Khafsah pumping station that is likely to delay post-conflict recovery [10]. was attacked and sewage is no longer treated [6, 14]. Increased prevalence of vectors and pathogens, lack Inter-generational health effects of a surveillance system, preventative programs and In addition, the effects of conflict are likely to be felt by infrastructure, and likely impaired levels of immunity children yet to be born. As previously described, war is a (as a presumptive consequence of malnutrition and pervasive environment in which trauma, infectious reduced immunization rates, and possibly of stress) disease, mental illness, and poor nutrition can affect have led to a greater overall burden of disease - including maternal physiology sufficiently to propagate biological ef- vaccine-preventable diseases - illustrated by the reemer- fects across generations. We discuss the evidence for this gence of polio and outbreaks of measles [6, 15]. in a related article on this topic [32]. Based on information from other conflicts, increases Long-term health effects in rates of preterm birth, fetal growth restriction, and The above rightly focuses attention on the immediate maternal infections leading to congenital abnormalities plight of Syria’s children, but evidence increasingly sug- are highly likely to increase [32]. Data from the Syrian gests that the stresses of war can have less visible effects conflict are currently sparse, but a study of 452 Syrian that last for years or decades. Children who survive refugee women in Lebanon highlighted some of the trauma may be left with lasting disability and mental problems. It found barriers to antenatal care, common scars, with consequences for their future health and so- exposure to violence (31 %) and a high rate of preterm cial and economic life skills [16, 17]. Rates of trauma births (24 %) [33]. Rates of Caesarean sections, with can remain high after conflict, and longer-term psycho- their associated morbidity, were also high (45 % of deliv- logical and psychosocial effects may be aggravated by a eries) as women were afraid of giving birth at unpredict- combination of the increased presence of weapons and able times in insecure environments [15]. There is normalization of violence within society [18]. Acute ex- similar evidence from Syrian refugees in Lebanon, where posure to violence can lead to mental illness, such as rates of Caesarian sections were 35 % (of 6366 deliveries post-traumatic stress disorder (PTSD) and anxiety, assessed) compared to approximately 15 % previously re- which can persist well beyond the conflict [19, 20]. A corded in Syria and Lebanon [34, 35]. Though relatively systematic review of mental health in refugees and small studies, similar outcomes would be expected in displaced people in Syria and surrounding countries the nearly 40,000 babies already born as Syrian refugees, (including 13 studies) found high and rising levels of where coverage of adequate antenatal care and skilled mental distress but also highlighted methodological healthcare workers at the time of birth is lacking [6, 36]. difficulties in obtaining accurate prevalence figures for The mechanisms by which intergenerational adverse ef- mental illness.

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