be government armies or military groups, invariably will try and ensure that the media is not accurately informed or that the other side is blamed.17 The effect of the war in Croatia (an upper middle income country) on a small community, however, has been described in detail.18 The community involved consisted of 28 500 children under the age of 18 years. In a 13-month period, 215 children were wounded and 46 killed. Over two-thirds of the children killed and wounded were boys. Children (both boys and girls) over the age of 10 years were more likely to be killed or wounded than younger children. Most of the children died or were injured as a result of machine gun ﬁre, rockets or bombs, including cluster bombs dropped from aircraft. A study of 94 children treated at one Croatian hospital follow- ing war-related injuries found that the majority were wounded during shelling or bombing or leftover explosive devices.19 Almost 40% of the children had a permanent disability. The long-term effects on the health of children (both physical and mental) are described in the following sections. DISPLACEMENT AND DISEASES Civilians will try and escape conﬂict areas. Twelve million children have been made homeless by armed conﬂict and direct conﬂict is the single most important factor in the creation of refugees.20 The highest mortality in groups of refugees are in children under the age of 5 years.21 The most common causes of death include diarrhoeal diseases, acute respiratory infec- tions, measles, malaria and severe malnutrition.21 Simple mea- sures, such as provision of soap and avoiding contamination of water, can have a major impact on reducing mortality.21 A combination of factors including displacement, infectious diseases, increased poverty and decrease in food production result in increasing levels of malnutrition in children during armed conﬂict. The armed conﬂict in Mozambique in the 1980s resulted in a documented increase in child malnutrition.22 The number of cases of malnutrition admitted to hospital in the capital increased dramatically over a period of 2 years and by 1990 malnutrition was the leading cause of child mortality in hospital.22 Sixteen per cent of the children admitted with malnutrition were from families displaced by war. A survey of rural areas at this time found that 53% of children under the age of 5 years had stunted growth and 7% were wasted. There were outbreaks of both cholera and measles, especially in overcrowded, displaced populations. ACCESS TO HEALTHCARE AND EDUCATION Direct conﬂict often results in difﬁculties for the civilian popu- lation to access basic services such as healthcare and educa- tion. It is important to recognise that in many conﬂicts, the aim is not to win the war but simply to de-stabilise the coun- try. This strategy was used by the USA in Nicaragua23 and South Africa in Mozambique in the 1980s.22 In both cases, military groups that were supported by foreign governments hostile to the government in power in the host country, tar- geted schools and health centres. The Mozambican National Resistance destroyed or looted almost half of the primary healthcare centres in Mozambique. They also targeted pri- mary schools and 45% of the primary schools closed and half a million children lost access to education.22 A similar strategy was used in Nicaragua where 106 of the 450 health units in the country became inoperable by the contras stealing medicines or placing landmines under the clinic walls.23 These tactics have unfortunately become increasingly popular with many different groups worldwide. Arch Dis Child 2012;97:59–62. doi:10.1136/adc.2009.178186 Review An illustration is the situation in Afghanistan. Attacks on schools and healthcare facilities have increased dramatically in recent years and in a 12-month period in Afghanistan there were 133 incidents of attacks on schools.3 Some of the attacks deliberately targeted female students and teachers. In a similar time period in Thailand, more than 100 schools were deliber- ately burnt down.3 In 2006, ﬁve staff members of Médicins Sans Frontières were deliberately murdered resulting in the withdrawal of Médicins Sans Frontières from Afghanistan. Armed groups that wish to de-stabilise a country are extremely unlikely to abide by legal conventions and it is essential that the arms trade is more tightly controlled and monitored to pre- vent these groups obtaining weapons. PSYCHOLOGICAL PROBLEMS Children who are either involved in or are witnesses of armed conﬂict are likely to experience a variety of psychological problems ranging from anxiety and depression to post-trau- matic stress disorder (PTSD). The prevalence of PTSD will clearly vary depending upon the nature of the armed conﬂict and what the child has observed. The prevalence of moderate to severe PTSD in one study of 234 children aged 7–12 years was just over 40%.24 One year after the conﬂict the preva- lence had fallen to 10%.24 The Rwandan genocide was one of the most violent conﬂicts in modern history. Over half a million civilians were murdered in a few months. A study of over 1500 Rwandan children and adolescents, 1 year after the killings, found that the levels of probable PTSD ranged from 54% to 62%.25 Ninety-ﬁve per cent of the sample were still re-experiencing symptoms. The authors felt that the extreme degree of violence witnessed (over 90% witnessed killings and had their lives threatened, 30% witnessed rape or sexual muti- lation and 15% hid under corpses) suggests that psychologi- cal resilience may be extinguished and that the prevalence of PTSD may not decrease. Children who are exposed to military violence for prolonged periods may develop aggressive behav- iour themselves and it is ironic that children in this situation may therefore see armed conﬂict as a solution to the problems, thus perpetuating the violence.26 WHAT CAN HEALTH PROFESSIONALS DO? The fact that one in six children worldwide lives in an area of armed conﬂict should be of concern to all health profession- als.3 27 The impact of armed conﬂict on child health is dra- matic in that as well as deaths from direct violence, deaths from infectious diseases and malnutrition increase dramati- cally.21 Health professionals need to be aware that politicians who are prepared to describe the death of innocent children as ‘collateral damage’ are unlikely to divert funding from military expenditure to either health or education. Health professionals unfortunately will need to constantly challenge the so-called wisdom of subsidising expenditure on weapons while cutting back expenditure on health and education. Health professionals can make contributions as individu- als by writing to local papers. Individually, they can also sup- port key organisations in reducing armed conﬂict, such as the International Physicians for the Prevention of Nuclear War.28 The International Physicians for the Prevention of Nuclear War have, as one of their main campaigns, reducing mortal- ity and morbidity from small arms, which unfortunately are a major problem worldwide. Health professionals can have a far greater impact when they work collectively, especially by the involvement of professional organisations which have a responsibility to make representations to politicians on 61