World needs a legally binding model to care for disaster-affected children
An infant or child is more vulnerable than an adult in disasters, and yet responses to protect them are voluntary, write Wilmot James and Stephen Nicholas
Children are the face of disaster relief. And yet disaster and post-disaster reconstruction plans the world over rarely acknowledge or provide for children. The International Red Cross and Red Crescent Societies have well-worked-out guidelines for the domestic facilitation and regulation of international disaster relief and initial recovery assistance but these are nonbinding and not legally enforceable measures by which countries can be held accountable.
It is an area of great concern and in need of an urgent remedy. Children are more vulnerable than adults in disasters. Because they are different anatomically, physiologically, immunologically, developmentally and psychologically, children require specialised care. Many well-defined aspects of paediatric care differ markedly from those of adults. Children need different dosages, medicinal formulations, sizes of medical and personal protective equipment, and age-and size-adjusted fluid and nutrition management.
In health security emergencies child-specific requirements influence triage protocols (treatment priorities), the approach adopted to decontamination, how to care for children separated from their families or guardians, and the treatment of those exposed to biological, chemical, radiological or explosive agents.
Young children are immunologically immature and more susceptible to malnutrition and micro-nutrient deficiencies, any of which can make them susceptible to infectious diseases. Physiological differences between children and adults result in age-related changes in pharmacokinetics that make it close to impossible to extrapolate paediatric dosing for medical countermeasure applications from adult data.
Children caught up in catastrophic circumstances caused by extreme weather events, war and civil strife appear to be increasing, adding to crises in Bangladesh, Myanmar, Yemen and Syria
Small children cannot swallow pills and medical countermeasures are seldom available in liquid form. Pre-existing maternal antibodies may interfere with diagnostic antibody detection assays, rendering them virtually useless in very young infants.
Children’s dynamic growth and development put them at increased risk to environmental toxicants. The reference population is very large as children under 15 years make up a quarter of the world’s population, 41% of whom live in Africa. Based on the World Health Organisation (WHO) data, African nations are the least prepared to prevent, detect and respond to major public health risks. Africa suffers more than 24%of the global burden of disease but has access to only 3% of health workers.
Sub-Saharan nations are among the lowest in the world with regards to the density of medical doctors, ranging from Botswana with one physician per 2,600 citizens to Ethiopia’s figure of one per 40,000. That the largest concentration of children live in the least prepared continent in the world constitutes the most alarming dimensions of a social catastrophe in the making.
There is little data on the availability of healthcare workers with paediatric expertise in Africa. To improve the level and quality of information available, Columbia University’s Program for Global and Population Health based at the Vagelos College of Physicians and Surgeons established a project the first phase of which is to map and conduct a survey of the key facilities that provide health services to children in strategic regions of sub-Saharan Africa, including bed capacity, human resources for healthcare and the scale and quality of paediatric medicine, public health, oral hygiene and nursing provision.
The assessment instrument under development is based on the 19 WHO/joint external evaluation technical areas of health security, which will be refined and turned into protocols by inserting child-sensitive elements specifically for surveillance, diagnosis and medical countermeasure responses.
The child-sensitive measures can then be applied globally in any new effort to assess the health security of children.
Certainly, children caught up in catastrophic circumstances caused by extreme weather events, war and civil strife appear to be increasing, adding to crises in Bangladesh, Myanmar, Yemen and Syria.
But it is about to get worse. In eastern and Southern Africa, for example, multiple and more frequent humanitarian crises resulting from conflict, economic shocks, climate change, natural hazards and disease outbreaks are forecast.
More than 17-million people (of whom 7.7-million or 45% are children) remain food insecure in the region. The unfolding humanitarian crisis will unfold with particular characteristics in four regions:
South Sudan and Uganda. The war in South Sudan has led to a catastrophic situation and the largest and fastest-growing refugee crisis in Africa;
The Horn of Africa. A combination of conflict, drought and disease outbreaks has left 9.7-million children, particularly in Ethiopia and Somalia, in need of assistance;
The Great Lakes region. Instability in Burundi has stretched the ability of its neighbours Rwanda and Tanzania to absorb more than 200,000 children refugees; and
Southern Africa. Countries are affected by drought, cyclones and disease outbreaks — including cholera, acute watery diarrhoea, plague, typhoid and yellow fever.
What is to be done? The 1989 UN Convention on the Rights of the Child is the most widely supported human rights treaty in history. The Hague Conference on Private International Law regulates transnational co-operation on child protection, intercountry adoption, crossborder parental child abduction and parental responsibility and contact across national boundaries. The UN Refugee Convention and its protocol provide special safeguards for children to have their asylum application examined individually and the child-specific context of persecution considered, irrespective of whether the child applies alone or applies together with a parent or caregiver.
Protocols added in 1977 to the 1949 Geneva Conventions prohibited the military recruitment and use of children under the age of 15, which is now recognised as a war crime under the 2002 Rome Statute of the International Criminal Court, applying to both government-controlled armed forces and nonstate armed groups.
What is required is a new rights-based model for the caring of children during and after disasters built on the following elements:
A disaster-wide rather than a country-based platform: a comprehensive strategy for achieving children’s rights on a regional or continental level;
Children’s budgets for emergencies: ensuring that there are adequate resource commitments for children in disaster management;
Children-in-disaster units: developing permanent structures in governments world-wide to ensure that priority consideration is given to children in emergencies;
Impact assessment and evaluation systems: ensuring that there is a systematic process to assess the impact of law and policy on children during emergencies;
A regular "state of children in disaster management" report: ensuring that there is sufficient monitoring and data collection on the experience of children during emergencies;
Making children’s rights known: ensuring awareness of children’s rights among adults and children; and
Independent advocacy for children: supporting nongovernmental organisations and creating children’s ombuds or commissioners for children’s rights.
A new rights-based model for looking after children during disasters will serve as a platform to draw attention to the needs of children that are recognised as different from the rest of the population. Children and adults have equal moral standing in the right to life.
But because children are legal minors, adults therefore have the special responsibility to fight for children’s concerns, to advocate on their behalf and to invoke the moral duty to protect them with thoughtful interventions.
• James is visiting professor of (nonclinical) paediatrics and international affairs, and Nicholas is professor of paediatrics and public health and co-director of the Program for Global and Population Health at the Vagelos College of Physicians and Surgeons, Columbia University.