They are recruited to act as fighters, porters, cooks, messengers, spies and sex slaves. They are often forced to bear arms and participate in killing. But the physical and psychological harm done to so-called 'child soldiers' is not limited to the combat zone. The collapse of civil society resulting from protracted conflicts and the unchecked abuses of marauding militias expose children to a range of health risks from cholera to malnutrition; from deliberate mutilation to perhaps a lesser known consequence of their deployment in conflict--sexual abuse.
"Most of the girls returning from these conflict zones have experienced extensive sexual violence," says Pernille Ironside, a child protection specialist working with UNICEF, who recently returned from a four-year posting in the Democratic Republic of the Congo (DRC), where sporadic fighting has been going on since 1998. "We are talking about systematic rape often accompanied by mutilation over extended periods, sometimes years. Over 200 000 women and children have been raped since the onset of the conflict." According to the United
Nations, between June 2007 and June 2008, in Ituri province in eastern DRC, 6766 cases of rape were reported--a number which probably represents only a fraction of the assaults taking place. Of these reported cases, 43% involved children; girls for the most part but also boys. The psychological trauma resulting from these experiences is accompanied by an elevated risk of sexually transmitted infections, notably HIV/AIDS. Traumatic fistula, the rupturing of tissues caused by violent sexual assault, is also widely reported. Obstetric fistula is also a problem. "We see many girls who are too young to give birth requiring surgical procedures," says Dr Robin Nandy, senior health adviser for emergencies at UNICEF's Health Section in New York.
Such injuries, along with the plethora of blunt instrument trauma, stabbing and gunshot injuries that result from violent combat, are the tragic staples of war-zone pathology, but they are not the only dangers child soldiers face, in the more than 15 countries where children are used in conflicts, from Afghanistan to DRC, Sri Lanka and the Sudan. "When one thinks of health needs in a conflict situation--and this applies to children and adults--there is a tendency to think of war injuries," says Nandy. "But it's important to recognize the threat posed by psychosocial trauma and common diseases in crisis situations--diseases like malaria, cholera and yellow fever, exposure to which results from the breakdown of social systems and increased vulnerability that occur in conflicts, especially when they are prolonged. A child that gets sick in a war zone does not get the treatment he or she might otherwise receive."
When children enter a UNICEF transitory care centre, they soon receive a general medical check-up followed by treatment where indicated. In DRC, the centres are designed for a three-month stay, and are often the children's first contact with normality after their horrific experiences. "Generally speaking [the children] are not arriving wounded," says Ironside. "They may have the scars of bullet and knife wounds, but these have usually healed." Hair-raising cases of fistula or mutilation aside, the principal damage done is psychological. …