Imperial College, 12 July, 2019
Let me start by thanking Imperial College and Centre for Blast Injury Studies (CBIS) for inviting me to give this speech today.
It’s less than two years since Imperial and Save the Children organised a roundtable on paediatric blast injury. That meeting gave rise to the Paediatric Blast Injury Partnership, which has brought together colleagues from different backgrounds – academic research, medicine and surgery, the military and civil society – united by a common purpose: to better understand the impact of blast injuries on children, and to put in place practical measures aimed at protecting children where possible and helping them recover where necessary.
The partnership has been fuelled by the energy, determination and commitment of some extraordinary people, many of whom are in this room. I want to thank Anthony Bull, Emily Mayhew, Paul Reavley, Nigel Tai, Michael Von Bertele, Seb Taylor, Steve Bree, Simon Horne, John Hargrave and Peter Skelton.
I also want to thank our humanitarian partners – Humanity and Inclusion, MSF and Syria Relief.
If you’ll forgive the institutional indulgence, I want to applaud the leadership of my Save the Children colleagues James Denselow, Arij Boureslan-Skelton, Amanda Brydon, Simon Edmunds and Ruairidh Villar.
The Paediatric Blast Injury Field Manual
It was Dr Malik from Syria Relief who initially requested a field manual to help guide his non-specialist medics in treating children injured by bombs in Syria.
Thanks to Paul Reavley and the heroic efforts of his collaborators, we now have the Paediatric Blast Injury Field Manual. This is an invaluable guide to surgeons and other medical staff treating children who have suffered blast trauma injuries.
Beyond Syria, the manual is being used in the Philippines, Nigeria, Afghanistan, Libya, Somalia, Lebanon and Ukraine. Thanks to support from the World Innovation Summit on Health, we will shortly have an Arabic translation that we shall be making available in Yemen and Iraq.
Save the Children is privileged to have been part of this project.
Our commitment to the partnership reflects the experience of our teams in conflict-affected countries. From Syria and Yemen to Afghanistan and the Rohingya refugee people living in Bangladesh, our colleagues are meeting and responding to the needs of children who have suffered life-altering injuries caused by explosive weapons, whether from airstrikes or landmines.
The Paediatric Blast Injury Field Manual is a response to real medical challenges. Sadly, the need for the manual is a reminder of a wider challenges. Medics in conflict-affected countries are dealing with a growing number of child blast injury trauma victims because armed actors are failing to abide by rules, norms and laws designed to protect vulnerable citizens.
How blast injuries affect children
We estimate that around 142 million children are living in or near areas of intense conflict. Some of these children have been directly injured. Others have experienced loss. Many have witnessed appalling acts of violence. And far too many are directly targeted for heinous acts of violence. In 2017, the United Nations documented over 25,000 grave violations of human rights against children affected by war, the highest number on record – and almost certainly the tip of the iceberg.
What is happening to children as a result of blast injury is a symptom of far-reaching failures of protection. I’ll come back to this point in a moment.
People often ask me what I remember most about visits to programme sites in countries affected by conflict. I have an easy answer to that question. It is the extraordinary resilience of children and their relentless, unyielding capacity for hope. Even in the most desperate of circumstances, children are able to imagine a different and better future.
Yet children are also distinctly vulnerable – and it is all too easy for adults to overlook that vulnerability.
I remember reading an early draft of John Hargarve’s blast injury literature review. This is a masterly overview of the state of medical knowledge on how blast injuries affect children. The review powerfully communicates a very simple truth: namely, that when it comes to blast injury children cannot be thought of as small versions of adults.
You might have thought the CEO of an organisation called Save the Children could have worked that one out without the help of an academic literature review, but I hadn’t.
Here are some of the background facts:
- Children are far more likely than adults to die as a result of blast injuries.
- Blast injury is a major source of conflict-related mortality for children. Evidence from Syria for the period 2011 to 2016 suggests that 83% of children were killed by blast injuries, compared to 12% of combatants. Of the 5,322 reported child casualties across five conflict-affected countries – Afghanistan, Yemen, Syria, Nigeria and Iraq – just under three-quarters were linked to blast injury.
- Children are more likely to experience head injuries and burn injuries which cover wider body areas.
- Following blasts, chest and abdominal trauma is common, with incidence varying between 32%-50% and peaking in children aged between 5-10 years of age.
- Younger children are more likely to require neurosurgical interventions (linked to skull-thickness effects).
- Young children are more likely to experience cervical spine injuries.
- Children have a disproportionate requirement for health services – both surgical and otherwise – and experience injuries of a greater intensity than adults.
Of course, many of the deepest wounds suffered by children affect their mental health. Just as the bodies of children respond differently to blast injury, so the minds of children cope differently with the trauma and distress that accompanies sustained anxiety, loss, and witnessing acts of extreme violence. We are now working with Education Cannot Wait and others to address the mental health crisis affecting so many children.
I visited the Iraq city of Mosul last year and saw for myself what conflict can do to children’s bodies and minds.
Looking at the piles of stone and twisted girders that were once homes provides a glimpse of the terror experienced by civilians trapped by urban warfare. It is impossible to know how many were killed or wounded by snipers and car bombs. What is clear is that many children emerged from the military devastation, and the three years of Isis rule that preceded it, carrying deep psychological scars.
You can’t quantify the impact of such traumatic experiences, but in a Save the Children survey conducted in Mosul almost half the children reported feeling grief either always or most of the time. Only 9% of those interviewed reported being able to think of a source of happiness in their lives. Only 25% of adolescents considered school a safe place – unsurprisingly given that most of the city’s schools were destroyed.
While I was in Mosul I met Rahaf*, aged 10.
She can’t tell you what caused the war that left her an orphan, killed her friends and robbed her of her childhood. But she can give you a child’s-eye view of the collective trauma, grief and loss that weigh on children across her devastated city. “I wake up and I witness war every day. I don’t want to go through another war,” she told me.
The blast injury work you are leading
Let me make two wider points about the blast injury work you are leading.
The first relates to the underlying problem. The extent of paediatric blast injury tells us something about the nature of many modern conflicts. In countries like Afghanistan, Syria, Iraq and Yemen conflicts are played out in densely populated urban areas. High-explosive weapons initially designed for use on open battlefields are increasingly deployed in cities, along with improvised explosive devices (IEDs) that produce indiscriminate effects.
As the International Committee of the Red Cross and others have highlighted, the wide-area effects of these weapons have devastating consequences for civilians – and we now know, thanks to the work of the Partnership, that children face distinctive risks and vulnerabilities.
That brings me to the second point.
David Miliband has described our era as an ‘Age of Impunity’. The phrase describes a generalised sense on the part of combatants that the ‘rule of law’ for protecting civilians has become irrelevant. It hard to disagree with that assessment.
Governments and non-state actors involved in many conflicts have built up an impressive charge sheet of possible war crimes and crimes against humanity. The Syrian government, backed by a member of the Security Council, uses chemical weapons and indiscriminate bombing of civilians and, in defiance of humanitarian law, hospitals such as the Marat National Hospital in Idlib; the Saudi-led coalition in Yemen, armed by the US and (unlawfully in the judgement of a recent Court of Appeal ruling) the UK, mounts humanitarian blockades, launches precision weapons that hit a school bus, and destroys schools and hospitals on a routine basis; we have witnessed in Myanmar what an Independent Fact Finding Mission of the Human Rights Council describes as actions that may constitute genocide, crimes against humanity and war crimes.
I could go on. But the point I want to make is that the age of impunity is underpinned by a culture of impunity, which can be thought of as an indifference to the rules, norms, laws and human rights provisions developed over generations to protect civilians and set boundaries. As Mark Lowcock, the Under Secretary general for Humanitarian Affairs, has pointed out, the laws designed to protect civilians have been strengthened in many areas. Yet there has been a decline in compliance.
This is a subject that extends well beyond the scope of today’s discussion but let me explain the link to your work on blast injury.
Consider the rule of proportionality – a cornerstone of international humanitarian law (IHL). Essentially, the rule, enshrined in its most basic form in Article 51 of Additional Protocol 1 to the Geneva Convention, prohibits attacks which may be expected to cause incidental loss of civilian life which might be excessive in relation to the military goal. Armed forces are required to undertake proportionality assessments to comply with IHL, and with the Rome Statute that governs the International Criminal Court (ICC).
We now have irrefutable evidence that children are far more vulnerable to blast injury effects than adults. Surely that evidence must now inform how militaries around the world interpret and act upon their IHL obligations. By the same token, failure to take account of the differential risks and threats faced by children should be used to hold accountable those who believe international laws and human rights obligations can be violated with impunity.
We’ve been in dialogue with the Chief Prosecutor of the ICC, Fatou Bensouda, requesting her office to review the new findings around the unique harm around Paediatric Blast. Where appropriate, we hope that she will draw on the evidence presented to determine whether combatants have properly assessed the proportionality and precautionary principles they are required, as a matter of law and rights.
Save the Children is drawing on the work of the blast injury partnership in other areas. The shocking state of evidence on injuries sustained by children reflects a failure to properly assess and document casualty profiles. To take one example, we still have no plausible estimates from the UK or the US for the number of child casualties in Mosul.
UK role in protecting civilians in armed conflicts
As the UK Government reviews its strategy on the Protection of Civilians in Armed Conflict we are engaging with ministers and officials to explore the adoption of new standards on casualty recording, to factor in harm to children in targeting and collateral damage assessments.
The UK could also play a leadership role in strengthening norms.
We have worked over many years to secure international support for the Safe Schools Declaration – a set of principles aimed at making schools protected sites. I’m glad to report that the Declaration has now been endorsed by 89 countries.
We now need a comparable initiative aimed at preventing the use of explosive weapons with wide-area effects in populated areas – and the UK could be a powerful mover in this endeavour. We will be citing the evidence on paediatric blast injury to make this case.
As many of you will be aware, Save the Children has been engaged for some time over the issue of arms sales to Yemen – and we see this as an area in which the UK can play a role in dismantling the culture of impunity. The bottom line is that you cannot have one set of rules for Saudi Arabia framed to reflect is value as an arms export market, and another set of rules for Syria or Myanmar. Universal rights cannot be diluted or adjusted to reflect political convenience, especially when they involve our responsibilities towards children.
Stop the War on Children
Let me conclude with a word on a campaign that I hope might be of interest.
At Save the Children we are marking our centenary with a Stop the War on Children campaign – a global call for action to protect children threatened by war. The campaign is rooted in the values that led to the foundation of our organisation.
As many of you will know, Eglantyne Jebb, one of our founders, was arrested in London’s Trafalgar Square for the “crime” of demanding an end to a British naval blockade preventing humanitarian aid from reaching famine-stricken children in Germany and Austria after World War I. She went on to build a movement aimed at protecting children from armed conflict. “All wars, just or unjust, disastrous or victorious,” she wrote, “are waged against the child.”
The evidence we are discussing here today suggests she had a point.
As the name of our campaign suggests, we are working with allies and partners around the world to stop the war on children. That means challenging the culture of impunity, advocating for accountability and – critically – supporting the recovery of children who have suffered physical or mental harm.
Let me conclude by assuring you that I remain fully committed to Save the Children’s continued co-chairing of the Paediatric Blast Injury Partnership.
As I said earlier, the capacity of children to hold on to hope is the most inspiring and humbling reminder of their bravery, and their vulnerability. Through the Paediatric Blast Injuries Partnership, you are bringing hope into the lives of children who deserve our help – and that is a cause worth fighting for.