Article Text
PDF
Statistics from Altmetric.com
Gaza, part of the occupied Palestinian territory and home to almost 2.3 million people, has been under Israeli blockade for the past 16 years and under occupation for decades. On 7 October 2023, Palestinian armed groups launched an assault on Israel killing 1200 Israelis and foreign nationals, mostly civilians and including 36 children, and abducting hostages, at least 30 of whom are children.1 2 Following this, Israeli forces launched aerial bombardments and ground operations in Gaza. A humanitarian pause to the hostilities came into force on 24 November 2023 and ended on 1 December 2023. As of 22nd January 2024, 25295 people have been killed in Gaza, 70% of whom are children and women, and thousands of children have been reported missing.2 3 A further 91 children have been killed in the West Bank by Israeli forces or settlers.2 During the humanitarian pause, 86 Israeli and 24 foreign national hostages were released, over 30 of whom were children, in exchange for the release of 240 Palestinians held in Israeli prisons, all of whom were children and women.4
The international community has a responsibility to protect children from the effects of armed conflict. Under international humanitarian law, the parties to the conflict are obliged to take all feasible steps to protect children and all civilians, and to allow and facilitate rapid and unfettered passage of humanitarian relief.5 Children also have the right to be protected in conflict and the right to survival under the UN Convention on the Rights of the Child (UNCRC). Children are more vulnerable in periods of armed conflict and their rights are routinely violated, as has been seen in conflicts in Ukraine, Yemen and Syria.6–8 Emerging data suggests that the rate of child deaths in this recent escalation of the conflict in Gaza when compared with other conflicts may be disproportionately high.9 The collective punishment of Gaza’s extremely young population amounts to a child health catastrophe, with lifelong and intergenerational consequences. Furthermore, according to the UN Commission of Inquiry, which has been collecting and preserving evidence of war crimes committed by parties to the conflict since 7 October 2023, ‘there is already clear evidence that war crimes may have been committed in the latest explosion of violence in Israel and Gaza’'.10
Recognising the vulnerability of children in conflict, the UN has determined six specific grave violations committed by parties to conflict as especially egregious and deserving of priority attention, which are listed in box 1.11 Monitoring of the six grave violations against children in war is led by the UN Special Representative on Children and Armed Conflict.11 12 In this ongoing escalation of violence, four of the six grave violations have been observed and reported (although not yet independently verified by an appropriately mandated entity) against children in Gaza, the West Bank and Israel: the killing and maiming of children; the abduction of children; attacks against schools and health facilities; and the denial of humanitarian access. We condemn all violations committed against children in this conflict as the rights of all children are universal, unambiguous and indivisible. In this article we focus on the violations of rights that have been observed and we discuss the current and future impacts of these violations on the health of children. We also make recommendations to stop immediate harms to children, and suggest means for the child health community to advocate for children’s rights in this conflict and beyond.
: The six grave violations against children during armed conflict
The killing and maiming of children.
The recruitment and use of children.
Sexual violence against children.
The abduction of children.
Attacks on schools and hospitals.
Denial of humanitarian access.
The killing and maiming of children
As of 11 January 2024, at least 10,000 children in Gaza had been killed.13 Additionally, 91 children were killed by Israeli forces and settlers in the West Bank as of 22nd January 2024, and 36 children were killed by Palestinian armed groups in Israel.2 Nearly 1.7 million people in Gaza are internally displaced due to the conflict.2 On 3 December 2023, the Israeli military issued immediate evacuation orders for 20% of Khan Younis city; the area was home to nearly 117 000 people before hostilities, and is currently hosting at least 50 000 persons displaced from the north in 21 shelters.4 The entire population of children in Gaza have nowhere safe to go, nor adequate provision of food, water, toilets and shelter.14 15
Amnesty International has reported the use of large bombs likely weighing up to 2000 lbs.16 This method of combat in a densely populated area inevitably results in staggeringly high civilian casualties.16 Additionally, the alleged use of white phosphorus by Israeli forces in densely populated urban areas in Gaza has been reported by Human Rights Watch in the current offensive and also reported in previous attacks.17 18 White phosphorus exposure results in deep thermal and chemical burns, and can cause multiple organ system failure, with survivors facing extensive scarring, physical disabilities, painful treatment, psychological harm and social exclusion. Children are considered more susceptible to harm from chemical weapons due to their physiology and body mass.19 These assaults on the lives, health and well-being of children and young people who have no place in the origins of the conflict is a moral outrage.
The UNCRC Article 6 elucidates a child’s inherent right to life and binds all parties to ensure to the ‘maximum extent possible the survival and development of the child’.20 UNCRC Article 19 also requires that states ensure the protection of children from violence, injury and abuse. International humanitarian law stipulates that ‘parties to a conflict must take all feasible precautions to avoid, and in any event to minimise, civilian harm. This can entail evacuating civilians or giving effective advance warning of attacks, which provides civilians enough time to leave, as well as a safe route and place to go’.15
Abduction of children
During the humanitarian pause, more than 30 children who were taken as hostages by Palestinian armed groups during their attack on 7 October 2023 were released1 and there is uncertainty over how many children remain as hostages. Human Rights Watch have reported the use of children in ‘hostage videos’, which they highlight is an ‘outrage on personal dignity’.21 News articles on the child hostages report that the children were subjected to inadequate food, sanitation and hygiene conditions, and to psychological trauma.22
Since 7 October 2023, the UN Human Rights Office has reported a dramatic increase in the arrest and detention of Palestinians, with no evidence of committing an offence in the majority of cases.23 Children are not immune to this; it is estimated that the Israeli military arrests and detains 500–700 Palestinian children yearly through military courts without basic safeguards for a fair trial and often via a process of administrative detention in which no charge is ever presented.24 25 Additionally, on 7 December 2023, dozens to hundreds of Palestinians sheltering in a school, including boys aged as young at 15 years were detained, stripped, tied up and transferred to an unknown location.15 The abduction and detention of children is known to be harmful to children’s physical and mental health, oftentimes with lifelong consequences for survivors.19
Attacks against schools and healthcare facilities
UNICEF reported attacks on 352 educational facilities between 7 October 2023 and 8 December 2023.26 As of 20 January 2024, 151 UN Relief and Works Agency (UNRWA) workers had been killed.27 Mass displacement of the civilian population has necessitated the use of schools as emergency shelters and therefore resulted in an even greater number of deaths when they are attacked. One example was the attack on the UNRWA Al Fakhoora School in the Jabalia refugee camp where approximately 20 000 individuals were sheltering.28 Healthcare facilities have similarly been attacked, with the WHO documenting more than 300 attacks on healthcare facilities as of 22nd January 2024.2 affecting 56 facilities and 59 ambulances. Médecins Sans Frontières has also reported the targeting of their vehicles by Israeli forces.29 The UNCRC highlights that all children have the right to the highest attainable standard of health and healthcare (Article 24) and the right to education (Article 28)20; the current attacks being inflicted on Gaza expose violations of these rights.
Denial of humanitarian access
The Gaza Strip has been under blockade for 16 years, during which time Israeli authorities have controlled the movement of individuals and imposed import restrictions on essential items such as food, construction materials, critical medical equipment and fuel.30 During the most recent offensive, Israel has cut fuel, electricity and aid supplies to Gaza under a ‘complete siege’, as described by Israeli defence minister, Yoav Gallant, and has also attacked telecommunications infrastructure, further exacerbating an already dire humanitarian crisis.31 On 21 October 2023, the first 20 aid trucks since 7 October 2023 were allowed into Gaza through the Rafah crossing carrying limited emergency supplies, which according to UN officials, was ‘a drop in the ocean of need’.32 Before the start of the humanitarian pause on 24 November 2023, a total of 1723 aid trucks had entered, with Israel allowing small amounts of fuel from 18 November 2023 for essential humanitarian operations.33 The restrictions on fuel and aid into Gaza have created a desperate situation for hospitals affecting children of all ages, including newborn infants requiring incubators that rely on electricity from fuel-dependent generators. Due to the lack of electricity at Al Shifa hospital, 37 premature babies were relocated to an operating room without their incubators over the weekend of 11 and 12 November 2023, 6 of whom had reportedly died by Monday, 13 November 2023.34 It also means the limited aid arriving in Gaza cannot reach all those who need it across the Gaza Strip.35
What do these violations mean for children?
Armed conflict is a major negative determinant of health that has short-term and long-term effects on children. Direct child health effects include the experience of multiple forms of violence, injury, disability and death from bombing, shooting, explosions and collapsing of buildings.36 Exposure to conflict can cause harm prenatally and 50 000 pregnant women in Gaza are at risk of adverse birth outcomes from maternal stress, physical harm, malnutrition and damage to healthcare infrastructure.37 38
Substantial and pervasive indirect effects of exposure to armed conflict include communicable diseases, a range of non-communicable illnesses that are both the result of and exacerbated by inadequate living conditions and environmental exposures, displacement, family separation, being orphaned and limited access to basic needs such as safety, shelter, food, clean water, sanitation, healthcare and education.36 The WHO and Save the Children have warned that disease could kill more people than the war itself and since the resumption of hostilities following the short-lived ceasefire, there have been further increases in infectious diseases.39 40 The current hostilities have caused disruption to childhood vaccination programmes, hampered the functioning of disease surveillance systems, damaged water and sanitation systems and reduced access to treatment, which together exacerbate the child population’s vulnerability to communicable diseases.40 The significant damage to Gaza’s health infrastructure will contribute to increased child morbidity and mortality beyond this period of active hostilities. The impact of conflict affects children throughout their lives.19 There is also decades of research establishing a connection between adverse childhood experiences such as the exposure to child abuse and violence and lifelong health outcomes, including chronic diseases and psychological disorders.41
The effects of conflict on children are heavily influenced by the vulnerability of the population prior to the conflict.42 For example, prior to the current offensive, there was a high prevalence of malnutrition in Gaza,43 with approximately 90% of preschool children consuming less than 75% of the recommended daily energy intake.44 With the current food shortages and inadequate living conditions malnutrition rates can be expected to increase.43 Acute and chronic malnutrition have adverse impacts on children’s future physical and psychological health, neurological development and future opportunities.42 45 Studies have found high levels of psychological trauma and impaired health-related quality of life including emotional functioning and psychosocial health in Gaza’s children, which are compounded by intergenerational effects of the long-standing conflict.46–49 The current escalation in violence against civilians in Gaza will further exacerbate the mental health situation and there is likely to be psychological trauma in the surviving child hostages; thus, highlighting the critical importance of long-term interventions and support for all affected children.
A call to action to protect children and their health
Further harm to children is preventable if urgent steps are taken. Governments and non-governmental actors must demonstrate in action that the lives of children in Gaza are worth no less than any other life. We support the calls made by multiple organisations, such as the United Nations agencies, including the WHO, non-governmental organisations and fellow health workers for the following:
An immediate and permanent ceasefire.
The release of all civilian hostages in Gaza.
Urgent provision of water, food, fuel, medical supplies, non-food items and shelter to Gaza.
An immediate reversal of the evacuation orders for all affected areas of Gaza.
Unrestricted, safe and sustained humanitarian access.
Immediate and absolute protection from attack for civilians, health workers, hospitals and schools.
Adherence and accountability to international law of all parties involved in the conflict.
Medical evacuation of severely injured, ill and pregnant citizens of Gaza to a safe country.
Resumption of the peace process and an end to the occupation in order to bring long-term safety to all children in the region.
Actions for the child health community:
Call for the formal implementation of the United Nations Special Representative on Children and Armed Conflict Monitoring and Reporting Mechanism to hold parties accountable for committing grave violations against children.
Demand objective, needs-based humanitarian aid for children in all conflicts, regardless of scale, political or strategic importance.
Continue to highlight evidence of the egregious impact of war on children through formal (eg, publication, news media) and informal channels (eg, social-media), especially where coordinated, collective actions are possible or where the voices of advocacy, human rights and humanitarian organisations can be amplified.
Join or develop a coalition of child health advocates in your country or region to work specifically on protecting child health in conflict.
Stand in solidarity with affected children and young people by joining peace and humanitarian organisations working towards preventing and ending conflict.
Stand in solidarity with health workers in Gaza who are facing intolerable circumstances and enormous workloads.
Push to embed data on the adverse effects of conflict on child health into policy recommendations and for use in the international legal system to hold responsible parties to account.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Footnotes
Twitter @BoukariYamina, @cinarervanur
Contributors YB, AK and TW came up with the original concept and YB wrote the first draft. All authors provided substantial edits to the draft and read the final version prior to submission. YB is responsible for the overall content of the article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement statement Commissioned; externally peer reviewed.
Provenance and peer review Not commissioned; externally peer reviewed.
Author note We have been careful to limit sources of data to UN agencies, global agencies or peer reviewed literature. The views expressed are those of the authors in their individual capacities and not the views of an organisation or employer.
The following authors are members of the International Child Health Group, affiliated to the Royal College of Paediatrics and Child Health: Yamina Boukari, Tony Waterston, Prudence Jarrett, Christian Harkensee, Erin Dexter, Erva Nur Cinar, Kerry Blackett, Amy Stevens and Delanjathan Devakumar. Hadjer Nacer is a member of the Faculty of Public Health.