1University of Western Ontario, London, Canada 2Academic Division of Child Health, University of Nottingham, Derbyshire Children’s Hospital, Derby, UK Correspondence to Imti Choonara, Academic Division of Child Health, University of Nottingham, Derbyshire Children’s Hospital, The Medical School, Clinical Sciences Wing, Uttoxeter Road, Derby DE22 3DT, UK; imti.choonara@nottingham. ac.uk Accepted 2 February 2011 Published Online First 9 March 2011 Arch Dis Child 2012;97:59–62. doi:10.1136/adc.2009.178186 Armed conﬂict and child health Michael Rieder,1 Imti Choonara2 Review SUMMARY Armed conﬂict has a major impact on child health throughout the world. One in six children worldwide lives in an area of armed conﬂict and civilians are more likely to die than soldiers as a result of the conﬂict. In stark contrast to the effect on children, the international arms trade results in huge proﬁts for the large corporations involved in producing arms, weapons and munitions. Armed conﬂict is not inevitable but is an important health issue that should be prevented. INTRODUCTION Unfortunately, over the last 500 years we have experienced more years of war than of peace in Europe, Africa and Asia.1 In the last decade there have been between 14 and 21 major armed conﬂicts each year.2 Although this may seem a relatively small number in comparison with the number of countries, the impact of war/conﬂict on child health is staggering. It has been esti- mated that more than 1 billion children were liv- ing in areas in conﬂict or emerging from war in 2006.3 Three hundred million of these children were under the age of 5 years. It is ironic that as weapons become more sophisticated and more legislation is passed to try and control war, the proportion of civilians involved as casualties has steadily increased (table 1). It is troubling to note that over the last century the ratio of civilian to military deaths has risen progressively. In part, this relates to the increasing range and lethal- ity of military ordnance; in 1902 lethal ﬁre was largely limited to line of sight, while contempo- rary military units can produce lethal injury for a radius of many kilometres. Additionally, urbani- sation and a shift in the focus and pace of combat operations have moved military action into closer and closer proximity to civilians, with predict- able results. Regrettably, the ‘empty battleﬁeld’ described in military texts is often not empty of non-combatants. Terrorist attacks on civilians have resulted in signiﬁcant numbers of children being killed or injured. Internal conﬂicts are usually associ- ated with even higher ratios of civilian to mili- tary casualties than the conﬂicts between nation states illustrated in table 1. The so-called ‘war on terror’ has also signiﬁcantly affected chil- dren. More than 1500 children are being held in detention in Iraq.3 Palestinian children as young as 12 years of age are being held in Israeli pris- ons and the transfer of Palestinian child prison- ers outside the occupied Palestinian territory into Israel has been noted to be in direct violation of the Fourth Geneva Convention.4 It is important to recognise that a cessation of violence does not necessarily result in a cessation of effects on child health. Psychological trauma following conﬂict is a signiﬁcant problem in children and additionally landmines cause both death and injury for many years after conﬂict. This article aims to explore links between different aspects of armed conﬂict and child health. WHO PROFITS FROM WAR? Civilians and children in particular who are caught up in a conﬂict, be it internal or between different states, invariably want to return to a peaceful life as soon as possible. The UK saw the largest ever demonstration in its history where an estimated 2 million people (almost 4% of the population) marched through London on an antiwar protest prior to the invasion of Iraq. In contrast to inno- cent civilians who wish to lead a peaceful life, one has to recognise that the international arms mar- ket results in enormous proﬁts for key companies involved in the development, manufacture and export of weapons and munitions. The total global military expenditure in 2008 is estimated to be US$1464 billion.2 Over 40% of this spending occurred in a single country, the USA, the defence expenditure of which is equiva- lent to that of the next 14 countries combined. The six largest arms-producing companies in the world consist of ﬁve American companies and BAE from the UK. Each of these six companies made more than US$1 billion in proﬁt in 2007.2 Boeing alone made US$4 billion proﬁt. The political inﬂuence of these major companies is considerable. The evolution of the major companies involved in arms sales occurred during the Cold War and issues about government–industry relations are not new. Concern about the inﬂuence of the ‘mili- tary industrial complex’ was ﬁrst raised by Dwight Eisenhower, the former US President, in 1961 when he stated “In the councils of government, we must guard against the acquisition of unwar- ranted inﬂuence, whether sought or unsought, by the military industrial complex. The potential for the disastrous rise of misplaced power exists and will persist.”5 The arms business is not a uniquely Western domain. Russia is the world’s second largest exporter of arms and in the last decade, China has doubled the number of weapons and munitions exported. High military expenditure in high-income countries has an adverse effect on child health in those countries. The USA has been discussing whether it can afford a universal health insurance scheme and yet does not question spending over US$600 billion per annum on weapons. Within the UK, despite a huge deﬁcit in the budget and the need for major cuts in public expenditure, the two main political parties are committed to spending between £20 billion and £95 billion on 59