The violence, suffering, and death from the terrorist attack on Israel and the Israel-Hamas War weigh on us all. Pediatricians—who are called to care for children and keep them safe and healthy—have been reaching out to the American Academy of Pediatrics expressing anguish, outrage, and a deep desire to help stop the killing, ease the suffering, and protect all children from harm.
We are shaken and pained by what is happening in Israel and Gaza, and we are also alarmed by the increasing acts of violence and intimidation we’ve been witnessing in this country toward Jews, Muslims, and those with ties to Israel or Palestine. Many pediatricians and the families they care for have experienced such incidents.
As antisemitic and anti-Palestinian hate speech have been surging on social media, acts of hate have also been increasing in the United States and around the world. There has been an unprecedented rise in incidents of antisemitism, Islamophobia, and anti-Palestinian racism in this country according to data from the Anti-Defamation League1 and the Council on American-Islamic Relations.2 And reports of violent hate crimes targeting Jews, Muslims, and Arabs have risen steeply across the United States.
As people at home and abroad confront these issues and as world leaders debate how to move forward, one thing is certain: all children affected deserve our unconditional support.
It will always be the mission of the American Academy of Pediatrics (AAP) to advocate for children’s protection, health, and safety, no matter what, no matter where—be it in the United States, Israel, Gaza, the West Bank, Ukraine, South Sudan, Armenia, Syria, Yemen, Myanmar, Ethiopia, Democratic Republic Congo, or other conflict-torn areas that receive less media attention.
As pediatricians, pediatric medical subspecialists, and pediatric surgical specialists, we understand that the profound cost of any war is measured in children’s lives—those lost to violence and those forever changed by it. We know that what happens to these children today and what we do for them will help determine what becomes of this generation tomorrow.
In 2018, the Academy published a policy statement3 and accompanying technical report,4 “The Effects of Armed Conflict on Children,” which began with the following statistic: 1 in 10 children are affected by armed conflict. By 2021, 1 in 6—or about 449 million children worldwide—were living in a conflict zone.5 Africa had the highest overall number of children impacted by conflict (180 million), followed by Asia (152 million), and the Americas (64 million). Today, that figure is tragically even higher.
Our policy details both the acute and long-term effects of armed conflict on child health and well-being and uses a children’s rights-based approach as a framework for the AAP, child health professionals, and national and international partners to respond in the domains of clinical care, systems development, and policy formulation.
Our policy calls on governments to safeguard children and for pediatricians and health organizations to be involved both in preventing and responding to armed conflict. It advocates for integrating core human rights principles set forth in the United Nations Convention on the Rights of the Child (UNCRC) treaty into US policy.
To fulfill these rights, the policy lays out a number of detailed recommendations for mitigating the harms of child conflict both in clinical practice and in social systems serving children. This includes ensuring child health professionals who care for children affected by armed conflict have access to training in trauma-informed care, which involves recognizing and mitigating the harmful effects of these experiences. And it highlights opportunities for public policy advocacy, which include:
Ending the participation of children younger than 18 years of age in armed conflict and ensuring all children are protected from torture and deprivation of liberty, including extended or arbitrary detention;
Upholding the Geneva Conventions with respect to maintaining the sanctity of safe places for children, ensuring medical and educational neutrality, and allowing children fleeing armed conflict to petition for asylum and be screened for evidence of human trafficking;
Ensuring that children are not separated from their families during displacement and resettlement, and in the event of separation, prioritizing family reunification;
Protecting children from landmines, unexploded ordnances, small arms, and light weapons through effective clearing efforts and strict control on their sale, ownership, and safe storage;
Affording children a voice in creating policy and programs that prevent and mitigate harmful effects of armed conflict; and
Providing children affected by armed conflict access to educational opportunities as part of an environment conducive to their reintegration into society.
| 2023 AAP Board of Directors . | 2024 AAP Board of Directors . |
|---|---|
| Sandy L. Chung, MD, FAAP | Benjamin D. Hoffman, MD, FAAP |
| Benjamin D. Hoffman, MD, FAAP | Susan J. Kressly, MD, FAAP |
| Moira A. Szilagyi, MD, FAAP | Sandy L. Chung, MD, FAAP |
| Dennis M. Cooley MD, FAAP | Margaret C. Fisher, MD, FAAP |
| Patricia Flanagan, MD, FAAP | Patricia Flanagan, MD, FAAP |
| Warren M. Seigel, MD, FAAP | Jeffrey Kaczorowski, MD, FAAP |
| Margaret C. Fisher, MD, FAAP | Patricia Purcell, MD, MBA, FAAP |
| Michelle D. Fiscus, MD, FAAP | Jeannette “Lia” Gaggino, MD, FAAP |
| Jeannette “Lia” Gaggino, MD, FAAP | Dennis M. Cooley, MD, FAAP |
| Gary W. Floyd, MD, FAAP | Susan Buttross, MD, FAAP |
| Martha C. Middlemist, MD, FAAP | Greg Blaschke, MD, MPH, FAAP |
| Yasuko Fukuda, MD, FAAP | Yasuko Fukuda, MD, FAAP |
| Madeline M. Joseph, MD, FAAP | Madeline M. Joseph, MD, FAAP |
| Charles G. Macias, MD, FAAP | Angela M. Ellison, MD, MSc, FAAP |
| Constance S. Houck, MD, FAAP | Kristina W. Rosbe, MD, FAAP |
| Joelle N. Simpson, MD, FAAP | Joelle N. Simpson, MD, FAAP |
| 2023 AAP Board of Directors . | 2024 AAP Board of Directors . |
|---|---|
| Sandy L. Chung, MD, FAAP | Benjamin D. Hoffman, MD, FAAP |
| Benjamin D. Hoffman, MD, FAAP | Susan J. Kressly, MD, FAAP |
| Moira A. Szilagyi, MD, FAAP | Sandy L. Chung, MD, FAAP |
| Dennis M. Cooley MD, FAAP | Margaret C. Fisher, MD, FAAP |
| Patricia Flanagan, MD, FAAP | Patricia Flanagan, MD, FAAP |
| Warren M. Seigel, MD, FAAP | Jeffrey Kaczorowski, MD, FAAP |
| Margaret C. Fisher, MD, FAAP | Patricia Purcell, MD, MBA, FAAP |
| Michelle D. Fiscus, MD, FAAP | Jeannette “Lia” Gaggino, MD, FAAP |
| Jeannette “Lia” Gaggino, MD, FAAP | Dennis M. Cooley, MD, FAAP |
| Gary W. Floyd, MD, FAAP | Susan Buttross, MD, FAAP |
| Martha C. Middlemist, MD, FAAP | Greg Blaschke, MD, MPH, FAAP |
| Yasuko Fukuda, MD, FAAP | Yasuko Fukuda, MD, FAAP |
| Madeline M. Joseph, MD, FAAP | Madeline M. Joseph, MD, FAAP |
| Charles G. Macias, MD, FAAP | Angela M. Ellison, MD, MSc, FAAP |
| Constance S. Houck, MD, FAAP | Kristina W. Rosbe, MD, FAAP |
| Joelle N. Simpson, MD, FAAP | Joelle N. Simpson, MD, FAAP |
In examining the entire policy in light of the Israel-Hamas War, we determined it was missing important elements to emphasize the protection of children during war and the Academy’s opposition to religious persecution of any kind. We voted unanimously to add the following to the policy statement:
Children should never be harmed because of the religious, cultural, and other beliefs and values of the child and/or their family;
Harm to children should never be used as a tool or tactic of war or conflict; and
Children should be protected from the direct effects of armed conflicts and their food, housing, health, and other basic needs safeguarded.
With the magnitude of the suffering and so many children hurting at home and abroad, this is a distressing time to work in pediatrics. The pain of our members is palpable; both the urgent desire to do all we can to protect children in Israel and Gaza and the fear and concern we are experiencing as acts of hate proliferate in the United States. Yet our common mission and the outpouring of support and solidarity among our member pediatricians reminds us there is light in the darkness.
We use our platform as the world’s largest pediatric organization to speak out against violence, hate, antisemitism, Islamophobia, and enmity toward Jews, Muslims, Israelis, and Palestinians and to speak up on behalf of all children suffering in armed conflict. We stand with everyone in the pediatric profession in these times of tragedy as we continue our work of healing, protecting, and caring for the world’s children.
Comments
A Prescription for Prevention and Healing in Times of War: The Haddon Matrix
If the Academy has not already done so, I would like to propose the Academy consider using the Haddon Matrix3 as a tool to advance the aims of the policy statement. The Haddon Matrix is an invaluable, but too-little known and often unused tool for systematically addressing harm/trauma prevention, mitigation and healing. Created in 1970 by physician William Haddon, Jr., the Haddon Matrix has played a key roll in the advent of child car safety seats, seatbelts, airbags and other injury, public health and harm-mitigation strategies. Directly applicable to the Academy’s policy on protecting children armed conflicts, a 2022 study using the Haddon Matrix was published in Prehospital and Disaster Medicine: Applying the Haddon Matrix to Frontline Care Preparedness and Response in Asymmetric Warfare.4
To provide a clearer sense of the form and the power of the Haddon Matrix, below is an example of the matrix and a few extracts from the article [with emphasis added].4:
The Haddon Matrix, using three Phases during which harm can be mitigated: Pre-event; During-event; and Post-event…and four Factors to address: Host (Human); Agent/Vector and Vehicle; Physical Environment; and Social Environment.
{An image of the Haddon Matrix can be inserted here}
“The [Haddon] matrix provides a conceptual framework that helps to examine problems systematically, breaking them down into smaller components to propose actions, proving to be an effective planning tool. It can help health leaders and planners in their decision-making process, analysis of threats and risk factors, identification of priority actions, allocation of resources, and after-action review. Therefore, the benefits of its application and use have been extended beyond injury prevention to better understand different public health issues and support public health emergency preparedness.4
“The new framework to enhance frontline care preparedness and response using the Haddon Matrix facilitated the identification of a set of strategies to support frontline health care workers in a more efficient manner. Since the existing approach and tools are insufficient for modern warfare, additional research is needed.4
“Asymmetry in warfare is not a new phenomenon. However, in the post-9/11 era, the asymmetry between state and non-state actors and the reaction to asymmetric threats have implications on the provision of medical assistance, in particular trauma care, in conflict zones. The assumption of reciprocity as an ethical imperative and motivation for respecting the law is often unrealistic. Instead, strategies to cause greater loss of human life represent a crude reality. These include the use of prohibited modalities and selection of civilian targets to replace military ones, posing major pragmatic and ethical challenges to prepare for and respond to the needs of the affected population.4
“Attempts to define and evaluate the application of a similar model involving civilians, recognizing the significant shift in the provision of medical care in such contexts from humanitarian organizations, have been registered. Wars in recent decades have been characterized by an increasing number of civilian casualties… Although comparative analyses between systems should be performed, situations of armed conflict or other emergencies in unsecure environments are extremely context-specific and require constant analysis and adjustment based on realities on the ground and tactical circumstances.4
References:
1. American Academy of Pediatrics Board of Directors, Protecting Children and Condemning Hate During a Time of War; (Prepublication Release | December 27 2023, Pediatrics (2023); https://doi.org/10.1542/peds.2023-065582
2. From the American Academy of Pediatrics| Policy Statement| December 01 2018; The Effects of Armed Conflict on Children; Pediatrics (2018) 142 (6): e20182585. https://doi.org/10.1542/peds.2018-2585
3. The Haddon Matrix; https://en.wikipedia.org/wiki/Haddon_Matrix
4. Salio, Flavio, et al; Applying the Haddon Matrix to Frontline Care Preparedness and Response in Asymmetric Warfare | Prehospital and Disaster Medicine | Cambridge Core DOI: https://doi.org/10.1017/S1049023X22001066
5. Barnett, Daniel J, et al; The Application of the Haddon Matrix to Public Health Readiness and Response Planning; Environ Health Perspect. 2005 May; 113(5): 561–566 Published online 2005 Feb 2. https://doi.org/10.1289%2Fehp.7491