children in conflict and disaster environments

Children in Conflict and Disaster Environments

David A RossParkes Professor of Preventive Medicine

QHP MSc MBBS MRCGP FFPHM FRCPCH FFTM FRCP (Glasg.) [email protected]

29 June 2019 RossDA_DMCC - Children & Conflict 1

mailto:[email protected]

Disclaimer

The opinions expressed in this presentation represent by own and not that of any employer that I may work for, including MOD. I have no

financial interest in any organisations that may act as a conflict of interest in relation to this

presentation.


AbstractThe author will contextualise the impact that

conflict and disasters can have on children using the backdrop of recent conflicts and disasters.

He will then describe the issues that need to be considered to safeguard children in such

situations and the medical consequences that result. The audience will be signposted to a new text that is freely available and will be useful for

clinicians and the key paediatric clinical skills that are required will be highlighted.

29 June 2019 RossDA_DMCC - Children & Conflict .3

Agenda

• Setting the scene• Children & their

needs• Management of the

sick child• Ethical

considerations• Case Study


An Ethical Dilemma?

Child is only survivor of his family following the earthquake in Nepal.

Discuss.


Fragility

Related to:

– Weak governance– Extreme poverty– Persistent inequality– Lack of territorial control– Frequent/persistent conflict– External shocks (e.g. environmental)– Inability to provide basic services


Conflict and Fragility

• State Fragility – when state structures lack the legitimacy or effectiveness to provide for basic development, security and human rights for their populations

• Conflict – prolonged armed struggle

Relationship between conflict and fragility29 June 2019 RossDA_DMCC - Children & Conflict 7

Disasters are on the Increase?

www.public.health.wa.gov.au/cproot/347/2/disaster%20medical%20assistance%20teams%20literature%20review%202006.pdf


http://www.public.health.wa.gov.au/cproot/347/2/disaster%20medical%20assistance%20teams%20literature%20review%202006.pdf

Balkans War #2[Sarajevo]

1992-1993:• Pre-war population = 650,000• 1993 = 360,000• 1400 children killed.• 12,800 children wounded.

UNICEF 1993.


OP Telic1 [Iraq 2003]

• Children were greatest clinical challenge.

• 48% of all civilian admissions to UK Field Hospital were children.

• 44/78 children had burns.

• 61 children required admission

Clinical Audit/Surgeon General’s Conference 200429 June 2019 RossDA_DMCC - Children & Conflict 10

Afghanistan

Disease profile of children 1m-12yrs in Kabul Children’s Hospital [12months/2002-2003]Disease Number % total cases Case

fatality%

Septicaemia 407 25 45

CNS infection 240 15 40

Diarrhoea 292 18 22

Respiratory infection 356 22 16

CHD ,CCF, Carditis 243 15 14

Renal failure 32 2 30

Hepatic failure 7 1 50

Diabetic KS 10 1 44

Malignancy 33 2 60

J Epidemiol Community Health 2006;60:20–23.


Women and Children of Afghanistan• 1/4 Afghan children die of preventable causes before the age

of five• 60% child deaths from diarrhoea, respiratory infection, and

vaccine-preventable diseases• 1/2 all children suffer from malnutrition; 250,000 die/yr from

malnutrition• 20% of all newborns are born malnourished• The maternal mortality rate is 2nd highest in the world

1,700/100000 • 2 million child refugees or internally displaced • 1/2 all landmine victims are children [5-10/day] • Child‘fighters’

[Oxfam, UNHCR, UNICEF]


Women and Children of Afghanistan

• Afghan girls suffer institutionalized discrimination, sexual and gender-based violence, and trafficking for sexual purposes • Health resources often reserved for adult men, with women-children denied medical care [male doctors won’t visit children's wards if located within the women’s ward, or see children accompanied only by their mothers]• Emotional damage from on going violence• IED target and ‘collateral damage’ injury increasingly common


OP Herrick 6b: Cause of ITU Admission

Neuro28%

Paeds7%

Burns5%

Trauma57%

NBI3%


Latest HERRICK Data

29 June 2019 RossDA_DMCC - Children & ConflictInwald DP, et al. J R Army Med Corps 2013;0:1–5. doi:10.1136/jramc-2013-000177

15

Children - Disasters

• 242m affected by natural disasters or armed conflict. • Women & children disproportionately affected.• 10m children affected by conflict, 66.5m, by natural disasters.• ½ of all those in refugee camps = children.

• ±115,000 children killed by armed conflict or natural disasters.-75% [85000] due to armed conflict. -25% [30000] due to natural and man-made disasters.

• Armed conflict responsible for more deaths, but 7x more people affected by natural disasters.

• Compelling images [NGOs] suggest children take priority in relief, rehabilitation, and recovery. Not the case. ‘Research’ is limited.

• Scant reference to children in manuals-publications.

[ICRC World Disaster Report, 2001]29 June 2019 RossDA_DMCC - Children & Conflict 17

Consequences…..• Death.• Long term disability• Rape-torture [common in ethnic

conflicts].• Loss of, separation from, parents

/family.• Break-up of community.• Internal-external displacement.• Loss of identity.• Damage to physical/emotional

development.• Loss of schooling / opportunity -

future.• Long-term psychological trauma.


….Leading to

• Increase in incidence of poverty related disorders [TB/infection /malnutrition].

• Increase in mortality within diagnostic groups.

• Increase in perinatal and child mortality Famine.

• Victims of politics-sanctions.


What are the immediate AID requirements?


Priorities for Intervention

1. Initial Needs Assessment

2. Measles Vaccination & Vitamin A

3. Water & Sanitation4. Food & Nutrition5. Shelter & Site Planning

6. Health care7. Communicable

Disease Control8. Public Health

Surveillance9. Human Resources &

Training10. Co-ordination11. Security


Triggers for Action

• Rise in mortality– Crude mortality > 1/10 000/day– Mortality in children aged <5 years >4/10 000/day

• Fall in energy supply– <1500 kcal/day in adults– <100 kcal/kg/day in infants and small children– Reduced z score or MUAC in 10% of children aged

<5 years– Wasting >15% of normal body weight


Other Indicators - Immunisation

• Assess need for campaigns on the basis of:– national vaccination records– questioning mothers– if children or parents have written vaccination

histories with them• Assess effectiveness of programmes by:

– recording % of children vaccinated – Can use children attending clinics as surrogate

value.


Expanded Programme of Immunisation

29 June 2019 RossDA_DMCC - Children & Conflict

Age Group /months Vaccines

0 – 2 BCG

2 – 9 OPV, DPTa

9 – 47 OPVb, MMR

Note. OPV = oral polio vaccine; DPT = diphtheria–pertussis–tetanus; MMR = measles–mumps–rubella.a Three total doses separated by 1-month interval.b Two total doses separated by 1-month interval.

24

Measles Vaccination & Vitamin A Programme

• 6 months - 12 years • >20% mortality in nutritionally at risk, exponential spread• mass campaign priority in first week - target 100%• not to be delayed until other vaccines are available• cold chain considerations• field definition:

– generalised erythematous rash lasting 3 days– temperature over 38C– one of : cough, red eyes, nasal discharge


Requirements for an Emergency Water Supply

• Minimum maintenance requirements (including hygiene needs) are 15-20 litresper person each day

• A feeding centre should aim to provide 20-30 litres/person/day and a health centre to provide 40-60 litres/person/day

• Safe storage should be provided near to homes


Malnutrition• Middle upper arm circumference

(MUAC) is a rough guide to nutritional status: normal > 14.0 cm, severe malnutrition <11.0 cm (6 – 60 months)

• A malnutrition emergency is when > 10% of children are moderately malnourished

• Weight for height ratio (z score) is more accurate than MUAC but is more complex to calculate


Nutrition• Involve specialist NGOs• Marasmus/ Kwashiorkor• Dry ration provision

– Support to families-self cooking including utensils

• Wet ration provision– Cooked food– Supplementary feeding programmes-

below 85 %wt/ht– Therapeutic feeding programmes - below

75 %wt/ht


Severe Malnutrition

• Intensive 24-hour care unit– Rehydrate– Oral fluids

• Routine care of infections and intestinal parasites• Systematic measles and Vitamin A• 3 hourly high energy milk therapy• Continue breast-feeding• Avoid Iron supplements• Second phase – more solids, local foods, fewer feeds, higher

calories, e.g. “Plumpy Nut”


1. Need of individual child = age dependant.

2. Need of family-society group.

3. Trauma, medical, educational, future…..

Other Considerations


Care issues:

• Malnutrition[short & long term effect]

• Infection[measles/TB/malaria/G-E]

• Dehydration• Trauma• Disease prevention

[sanitation/water/vaccination]• Psycho-social• Protection of “Rights”


Safeguarding & Advocacy


One child’s story, 1/1850 later unaccompanied [orphaned] children:The roof collapsed but created a hole through which the three children could breath. They where trapped in a corner of the room…[she] was found one day after the earthquake struck, her face injured, the dead bodies of her parents lying next to her… ‘I kept shaking the bodies of my parents asking them to wake up and take me out of there’, she says. ‘I cried and shouted a lot’.. ..’please save my father and mother. I need them’…”.

Bam Earthquake [26.12.03]


Obligations to treat

• Geneva Convention & Additional Protocols– Obligation as “occupying power”

• NATO principle of universal emergency care– Treat any person with life/limb/sight threatening injury

• UN Charter for Rights of the Child– Children must be treated by competent, trained professionals


Essential Services

• Diagnostic and curative

• Nutritional– Surveillance– Feeding Programmes– Vitamin supplements

• Immunisation


Children are not small adults!!• Differences include:

– Anatomy (e.g. size, more pliable skeleton). – Physiology (e.g. age-related variations in vital signs,

↑metabolism). – Immunology (e.g., immaturity,↑infection). – Varied development (e.g. inability to vocalize

symptoms dependence on others for necessities of life).

– Psychology (e.g., age-related response to trauma, major psychiatric disorders such as depression).

• Increased vulnerability, long-term implications, physical & psychological.


Children• ‘Normality’ changes with

age.• Think physiology +

development.• Children world over have

similar needs.• 4 broad groups: <1yr….1-

5…5-12…>12.• In practice >12 = adult.• First [basic] principles

apply.


Normal physiological values:


The “Sick Child & Illness Markers

• Fever• ‘Confusion’• Difficulty in breathing• Pain [localised-pointer]• Feed refusal• Persistent vomiting-diarrhoea


General Assessment

• General Colour• Mental Status• Responsiveness• Activity, Movement & Muscle Tone• ?Age-Appropriate Response [To Parents, you,

pain]• “Looks Good” vs. “Looks Bad”• “Common sense”


Children – Common Medical Emergencies

• Respiratory:– Asthma/wheezing– Croup– Bronchiolitis

• Shock: – Infective – Hypovolaemia (e.g.

gastroenteritis)– Anaphylaxis

• CNS: – Status epilepticus– Meningitis– Encephalitis– Drug intoxication


Common Diseases

• Acute respiratory infections• Cholera• Other diarrhoeal diseases• Measles• Malaria• Meningitis


Children - DehydrationMild = 5% Moderate = 10-15% Severe = 15%+

HR N increased rapid-weakBP N N lowUrine output ↓ ↓ ↓↓Mucus membranes

Sl dry dry parched

fontanelle N N/sunken sunkentears N little absentskin N Decreased turgor Tented/mottled

CRT <2secs 2-4secs >4secs


Broselow Tape


Parents

• A child’s anxiety will be enhanced by parental separation.

• Parents are part of the treatment (after security search).

• Children may be frightened by (military) uniform.• Children will not understand why you are doing

an intervention, only that it is hurting.• Remember pain relief.


Case Study

13 year old girl who was shot and paralysed from L2 by NATO forces when she was acting as a spotter for her Taliban father. Now stable and waiting for father to pick her up from the Field Hospital.

Discuss.


Acknowledgements

• Dr Ilya Kovar• Prof Euan Ross• Col B Moorthy

Friends and Mentors29 June 2019 RossDA_DMCC - Children & Conflict 54

children in conflict and disaster environments

Documents