Health Reach: Helping Children Affected By War

By Joanna Santa Barbara

During and soon after the militarized phase of the War against Iraq (which continues to kill with an economic noose), a group of young adults from several nations and professional disciplines joined in an effort to tell the truth about what the war has done to ordinary people in Iraq. They went as the Harvard Study Team and conducted household surveys of conditions of life in Iraq. Then they told the world of the suffering caused by the so-called "surgical strikes" and, later, the economic sanctions.

When the Balkan Wars began soon after, two young Canadian doctors, Robbie Chase and Eric Hoskins, who had been part of the Iraq study, wondered if they should try to do something similar in that region. They gathered a group of activists, myself included, drawn mainly from the Centre for Peace Studies and the Centre for International Health at McMaster University. (CIH was abolished last year in a spasm of university belt-tightening.) Our new group took the name "Health Reach" and was headed by Graeme MacQueen of Peace Studies and Vic Neufeld of International Health. We won funding from Health Canada, and our projects, centred on the Health of Children in War Zones, began to evolve.

Field Projects

We mounted field projects in Former Yugoslavia, Sri Lanka, and Gaza to investigate the impact of war on the physical and mental health of children. The group, however, was interested in more than understanding the consequences of war. We wanted to pursue projects to rehabilitate children affected by war, and to see if health interventions could advance the attainment or preservation of peace. A "Health to Peace" working group was set up to look for past and current examples where health interventions might have advanced peace.

We paid attention to making the work culturally relevant and appropriate to the regions of the field studies. In each field study there was close partnership with indigenous non-governmental organizations. These NGOs played a major role in designing each project. Members of the group tried to keep abreast of the developing understanding of "best practices" in humanitarian and development work. In Croatia and Sri Lanka, where there were attempts to help children with the psychological and moral impact of the war, the projects included evaluating the effectiveness of the interventions.

GAZA

The Health Reach work in Gaza remained true to the original goal of surveying the physical and mental status of children affected by war. Working with the Gaza Community Mental Health Program, we surveyed 650 children between the ages of six and 16, using several instruments to measure exposure to traumatic events, symptoms of post-traumatic stress disorder (PTSD), symptoms of attention deficit disorder, anxiety, depression and poorly socialized behavior. Our researchers measured these effects on the children, and also on their parents and teachers.

Children scoring higher than a cut-off score - a score established at the same level a Canadian child would be considered in need of help - were deemed to be suffering from a disorder. In Ontario, one in five young people suffer from symptoms at this level.

Almost all the Gaza children had experienced at least one traumatic event. The most common experiences were being tear-gassed (70%); having one's house searched, with damage caused (61%); seeing shooting, fighting, or explosions (54%); and seeing family members arrested and humiliated (37%). The average six to 16-year-old had suffered three such events, some of which were worse than those named above, for example, seeing family members injured or killed, or being injured themself.

These figures make it clear that a typical childhood in Gaza included witnessing or experiencing the violent events associated with this particularly deadly conflict.

The survey further shows that by standards used elsewhere, the Gaza children suffer very high levels of psychological disturbance, with boys more affected than girls for some disorders. In particular, for the cluster of disorders including anxiety and depression, six to 11-year-olds showed rates of 56% among boys and 47% among girls; 12 to 16-year-olds showed rates of 36% for boys and 35% for girls. These are extremely high levels of distress. Still higher levels of post-traumatic stress disorder were found (91% of boys and 84% of girls had mild PTSD or worse), for attention deficit disorder and for behavior infringing social rules.

All of these categories of psychological disturbance were significantly correlated to having experienced traumatic events. This relationship emerged clearly from this survey. It is known from other studies that children's mental health worsens under conditions of economic hardship and strain on community functioning, both of which are conditions of this conflict and others.

This project intended to raise awareness of the mental health needs of Gaza children and to assist in planning and funding services for them.

Croatia

Working with two Croatian refugee assistance organizations, Small Steps and the Society for Psychological Assistance, we decided there was enough material about the impact of war on children in Croatia. The project turned to design interventions that might assist children's psychological coping and modify the ethnic antipathy that characterized this bitter conflict. The project group designed a curriculum for children in grades four, five, and six. It began with sessions that enabled children to express and validate their distress caused by their experiences associated with the war. The program continued to teach communication skills, conflict resolution, human rights, awareness of ethnic bias, and the development of a vision of "peaceful living."

Teachers received training in the curriculum, and first began to teach it in 1996. The researchers carried out pre- and post-testing of psychological factors on children in the classes that had studied the curriculum, on classes in the same school that had not, and on classes in schools where it wasn't taught at all -250 children altogether. Teachers taught the curriculum in weekly sessions of two hours over four months. It involved much free expression, play, art, and singing - quite a departure from the generally formal style of Croatian pedagogy. One year later, the same children received a second post-test.

The results were gratifying. There were significant benefits from the intervention:

The children's symptoms of distress improved (compared with the control group ) and improved still further over the following year.

The children who received the intervention showed a significant decrease in hatred toward Serbs, which continued in the following year. This finding was the more remarkable given the general climate of intense ethnicization that prevailed at the time, especially as conveyed on television.

The intervention induced a significant increase in acceptance of nonviolent conflict resolution, which also held over the following year. However, the children who scored the lowest on social skills and acceptance of non-violent resolutions in the pre-test (30%) did not change.

The more children were exposed to traumatic events in the war, the more symptoms of post-traumatic distress and depression they displayed.

Exposure to very traumatic war events and level of post-traumatic symptoms did not correlate with the level of ethnic antipathy in children. This finding does not support the common idea that those people psychologically traumatized by war will go on to fight in the next one.

The intervention was welcomed by the children and teachers, and accepted by the Ministry of Education in Croatia. UNICEF and CARE supported its extension to other schools.

Sri Lanka

This project began with a survey of the psychological impact of war on children in an east coast region of formerly severe violence. This was intended to raise national awareness of this issue. It went on to use the "Health to Peace" concept by combining interventions designed to help children with their emotional suffering alongside interventions to help reconcile ethnic communities who were former antagonists in the violence.

Interviewing children about Symptoms

The Health Reach group worked with the Family Rehabilitation Centre of Colombo. As with all the Health Reach projects, most personnel were indigenous to the region studied. Three hundred children in Year 6 (about 11 years old) in eight villages were carefully interviewed about their war-related experiences and their symptoms of psychological distress. Exposure to traumatic events varied according to the geography of the war, but in this population, 40% had seen shooting close by; 46% had suffered deprivation of shelter, food, or water; 40% had been forced into hiding in bunkers or the jungle; 38% had witnessed someone being killed, injured or taken away by the army; and 13% had lost a family member to death and 16% to "disappearance." One in four children had personally experienced violence due to war, ranging from having their home looted to being tortured, jailed, or raped.

The survey revealed that 20 % of children suffered from severe symptoms of PTSD and 38 % from moderate to severe grief symptoms. These two conditions often affected the same child, as did chronic abdominal pain and depression (one in five children had felt life was not worth living during the past week).

Using the "Health to Peace" concept, and the inspiration of Paul Hogan, a Toronto artist, this project went on to establish an unusual intervention, the Butterfly Garden. A children's garden was built on the site of an old monastery garden. Children came from schools and orphanages from several ethnic groups of the area - Muslim, Tamil Christian, and Tamil Hindu. The program ran after school and on the weekends for six to nine months. There was a quiet "Cuckoo's Nest" where the children can talk to a counselor about their experiences. Meditation and ritual are used for healing. Children also played, created stories and dramas, produced art work and costumes, tended the garden and helped heal hurt animals.

Methods of evaluating this complex and multi-level project are currently being developed.

These three projects had a common starting-point. They set out to help war-affected children, and evolved differently according to the circumstances of the project sites and partner organizations. What did they accomplish?

Contribution to understanding

The projects have helped to raise awareness of children's suffering during and after war. Unfortunately, there has been no reaction from decision-makers. The Gaza and Sri Lanka projects show very high levels of psychological distress in children. The Gaza project shows very high rates of common mental health disorders in children. The lack of correlation between both exposure to traumatic events and level of post-traumatic stress symptoms with degree of ethnic antipathy is useful in refining our understanding about the causes of ethnic antipathy.

The Croatia project demonstrated the potential to relieve some of the stresses affecting children, although the effect was small. This is important information because very few similar projects throughout the world have been properly evaluated.

The curriculum in the Croatia project brought about small but lasting changes in the children's ethnic antipathy, even though the children's cultural environment was rife with many contrary messages.

Prevention

This last finding has very broad implications. Today, almost every human society has to deal with ethnic diversity, and often religious diversity, sexual orientation, or ability diversities, as well. Devaluing diversity is a prominent cause of suffering in, for example, Canadian high school teens, who experience ridicule, injury to self-esteem , exclusion from groups, and violence. Devaluing diversity is a necessary condition for ethnic cleansing and genocide. It is a contributing factor in about two-thirds of the world's current wars.

Canada has made significant accomplishments in creating a nonviolent, diversity-valuing society, but anyone from a minority group in Canada is aware of many flaws in how we treat and respect each other. We have so much more to learn. In Croatia, we learned a tiny bit more about what works in helping children value (or, in this case, barely tolerate) diversity.

This topic deserves more study, especially as we approach the Decade of the Culture of Peace and Nonviolence for the Children of the World.

Joanna Santa Barbara is a child & family psychiatrist and Assistant Professor of Psychiatry, McMaster University, and she teaches peace studies there.

Peace Magazine Fall 1999

Peace Magazine Fall 1999, page 26. Some rights reserved.

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