When is enough, enough? Humanitarian rights and protection for children in conflict settings must be revisited

By Zulfiqar A Bhutta, Robert Harding chair in global child health,Georgia B Dominguez, research assistant, Paul H Wise, Richard E Behrman professor of child health and society

9 September 2024
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Protecting the lives of children in Gaza and other conflicts requires changes to the rules of engagement and global responses to all conflicts affecting civilian populations, argue Zulfiqar Bhutta and colleagues

Protecting the lives of children in Gaza and other conflicts requires changes to the rules of engagement and global responses to all conflicts affecting civilian populations, argue Zulfiqar Bhutta and colleagues

The rules of war and existing regulations have become increasingly unable to protect civilians from harm in conflicts around the world. The large death toll among children in Gaza continues to provide the most tragically prominent example of this reality. More broadly, international institutions and humanitarian norms have remained impotent in preventing mass civilian casualties in various settings, including Ukraine, Sudan, and Tigray (1, 2, 3). Much has been said on the genesis of the Gaza conflict and other conflicts, and the tactics being employed by the combatant parties (4), but here we examine the Gaza conflict’s humanitarian effect on children and its implications for the protection of children in other conflict settings around the world.

The attack on Israel by Hamas on 7 October 2023 triggered a devastating military response by Israel that is still ongoing in September 2024. Over the past 10 months in Gaza, the protections afforded civilians in international humanitarian law have been largely ineffective (5). The 1994 genocide in Rwanda is estimated to have killed between 500 000 and 1 million people (6), but other than this there have not been as many civilian deaths in such a short period. The UN Office for the Coordination of Humanitarian Affairs (OCHA) reports that 40 534 Palestinians were killed from 7 October 2023 to 28 August 2024, many of them women and children (7). The reliance on the Gaza Ministry of Health for casualty figures has been questioned, particularly as these numbers do not well distinguish between civilian and combatant deaths and cannot distinguish between the number killed and those who remain listed as missing. Nevertheless, independent assessments have generally substantiated the early tallies of the Gazan ministry, although more recent casualty data may be less reliable as the health information system in Gaza has been largely destroyed and the full numbers may be evident only once the rubble is cleared (8, 9).

The high numbers of child deaths have primarily resulted from the use of explosive munitions in densely populated areas of Gaza under which Hamas has built miles of tunnels for military use. International humanitarian law permits violent attack on identified military targets but not when "the harm to civilians would be excessive in relation to the concrete and direct military advantage anticipated" (10). Israel has yet to provide sufficient evidence to counter the contention that the civilian harm associated with many of its attacks has been disproportionate to the intended military objectives. Israeli attacks have also heavily damaged schools, hospitals, and other healthcare facilities and injured thousands of patients and healthcare workers (11). Hundreds of healthcare workers remain in Israeli detention (12). Other civilian infrastructure has also been struck, including water and sanitation facilities. Hamas and other Palestinian armed groups attacked at least 24 Israeli localities on 7 October, including an open air music festival and "deliberately killed, injured, mistreated, took hostages and committed sexual and gender-based violence against civilians, including Israeli and foreign nationals" (5). Forty children were reportedly killed during these attacks and around 252 hostages were taken (5).

International humanitarian law distinguishes between the why of war and the how of war. Even the strongest justifications for going to war do not justify violating humanitarian laws in how the war is fought. Although it is important to recognise the larger context of the conflict, particularly Israel’s blockade of Gaza (by land, sea, and air) since 2007, this does not legitimise the atrocities perpetrated by Hamas on 7 October, which were clear breaches of international law (10). Neither can these atrocities, however barbaric, legitimise violations of international law in how Israel is conducting its military operations. In May 2024, the International Criminal Court issued arrest warrants for both Hamas and Israeli leaders, charging them with war crimes (13). Humanitarian concerns have also been raised regarding the custodial conditions and legal proceedings of hundreds of Palestinian children in Israeli detention (14).

As well as increasing injury and death among children from military assaults, the destruction of food and water supplies, housing, and healthcare raise serious concerns about the indirect and long term effects of violence on children’s health (15). The UN has reported that children have already died of acute malnutrition and dehydration (5). Recent assessments by the UN’s Food and Agriculture Organisation and the Famine Early Warning Systems Network (FEWS NET) have warned that food insecurity is widespread and, although definitive data are not available (16), conditions of famine may already exist in parts of Gaza, with potential longstanding and possibly intergenerational consequences (17). Recent evidence of polio virus circulating in Gaza, including the first case of type 2 virus in over 25 years, has triggered an emergency vaccination response (18).

Protecting children in war

The nature of violent conflict is always changing. With the intensified wars in Ukraine and Gaza, the decades long predominance of intrastate, civil conflicts, has shifted to interstate wars with a large increase in casualties (see fig 1 in supplementary data). Of special concern for safety of children, are protracted combat operations in densely populated urban areas, particularly when explosive munitions (aerial or artillery) are employed against combatant groups mixed with civilian populations (19). We reviewed the available evidence regarding conflicts with populations under siege or exposed to large scale, urban warfare in modern times. Figure 1 compares the mortality associated with selected, recent urban conflicts, with special attention to deaths among children. Although civilian casualties have been considerable in all examined cases, none have had the number of civilian deaths, especially among children, as in Gaza since last October.

Figure 1

Deaths in recent urban conflicts (see supplementary data for further details and references). Gaza figures up to 28 August 2024; published data on Homs and Gaza do not differentiate between combatants and civilians. There are conflicting claims around total Hamas combatants (Hamas sources claimed 6000 deaths; Israeli sources claimed 12 000)

The UN has identified six violations of international humanitarian law: the killing and maiming of children; recruitment and use of children by armed forces and armed groups; sexual violence against children; attacks against schools or hospitals; abduction of children; and denial of humanitarian access (20). However, children are heavily dependent on several humanitarian requirements that extend to all non-combatants, including the secured ability to exit areas under siege or deemed unsafe, the protection of medical systems, and access to necessary relief supplies. Table 1 lists current international standards supporting the rights of children and civilians in conflict and humanitarian settings. In addition, several UN resolutions also support action to prevent sexual and reproductive violence against women and girls, including resolutions 1612, 1820, 2467, 45/28, and 2601. None provide specific guidance on implementation or consequences for non-compliance.

Table 1

International standards related to children in armed conflicts (see supplementary data for further details and references)

YearNamePotential amendments
International legal frameworks 
1949Geneva conventionsFour treaties and three protocols that establish international humanitarian law by providing specific rules and limits to war. Section is needed to outline clear accountability measures that will be enforced when laws are breached by individuals, groups, and states
1998Rome statute of the International Court of JusticeEstablishes the International Criminal Court’s structure and authority. An internal policing authority is needed to ensure states comply with ICC rulings and arrests
UN conventions and declarations 
1948Universal Declaration of Human RightsNone
1948Convention on the Prevention and Punishment of the Crime of GenocideAll articles outline the definition and prohibition of genocide. Section is needed to outline clear, effective penalties that will be enforced when genocidal acts are committed by individuals, groups, and states
1959UN Declaration on the Rights of the ChildAll principles outline the rights and freedoms of children. Section needed to specify the types of protection and relief children should be promised and in what circumstances (ie, conflict and humanitarian settings)
1974UN Declaration on the Protection of Women and Children in Emergency and Armed ConflictAll statements reaffirm women and children to be the most vulnerable members of the population who require special protections in armed conflicts. Section needed on clear action by the UN or regional bodies in the event of non-compliance and gross violations
1989UN Convention on the Rights of the ChildAll articles outline the special safeguards and care children require. Inclusion of elements of protection and safety including safe passage and evacuation in the event of conflict
2000Optional protocol to the convention on the rights of the child on the involvement of children in armed conflictAll articles reaffirm the Convention on the Rights of the Child and further calls for the special protection of all children <18 years old encountering armed conflicts. Inclusion of specific accountability measures for states who recruit, train, and use children <18 years old. Inclusion needed of specific rehabilitation and reintegration activities required for children who are victims of armed conflict

The special vulnerabilities of children are addressed by a series of provisions in international humanitarian law, including the 1949 Geneva Conventions, 1977 Additional Protocols, the Convention on the Prevention and Punishment of the Crime of Genocide, and the UN Convention on the Rights of the Child. However, processes for ensuring compliance with these provisions remain inadequate and full accountability for violations remains elusive (21). The International Criminal Court (ICC) has authority to investigate and prosecute individuals, including heads of state, for serious breaches. However, the ICC remains dependent on cooperating states to enforce accountability measures (22). It is also evident that states often use their international influence, resources, and sophisticated judicial systems to delay and ultimately impede accountability.

Humanitarian voice for children

Clearly, children share many protections with other non-combatants in these environments, protections that demand immediate implementation in Gaza, Ukraine, Sudan, and in all other areas affected by violent conflict. We argue that children possess distinct claims to protection and care in settings of violent conflict, and that the special developmental vulnerabilities and societal roles of children, many reflected in international law, necessitate special steps in full compliance with humanitarian laws and norms.

The first, and most fundamental, step to protect the children of Gaza is to immediately end combat operations that endanger civilians as well as soldiers: to stop the killing. If there is no cessation of fighting, it is vital to permit and facilitate the evacuation of children, their families, and all civilians to areas of safety (23, 24). Israeli warnings of impending attacks and the establishment of corridors of safe passage have proved largely ineffective. The Geneva Conventions require that a besieging party permit the evacuation of children and other vulnerable civilians from a besieged area, a condition that is not being met by the near total closure of all crossings from Gaza. Unlike the welcome provided by neighbouring countries for the more than five million women and children fleeing the war in Ukraine (25), families in Gaza were not permitted or provided safe passage to move to any of the bordering states. The evacuation of children with catastrophic illness to advanced medical facilities in other countries has also proved far more difficult in Gaza than in Ukraine (26). There is also a widespread fear that departing families and children would never be allowed to return, a fear rooted in the infamous Nakba (catastrophe) of 1948, in which 700 000 Palestinians were displaced by Israeli militias or fled during the Arab-Israeli war of 1948 and barred by Israel from returning to their homes and lands (27).

Second, children are particularly vulnerable to the indirect effects of the war (28). Protections for essential civilian infrastructure remain critical. In addition, adequate relief supplies must be permitted entry and distributed appropriately to civilian populations. The obstruction of adequate relief supplies is a core component of the ICC’s charges of war crimes against Israel (13). Moreover, public statements by some Israeli leaders soon after 7 October have lent support to accusations that Israel is using starvation as a weapon of war (29). This contention, coupled with the destructive military operations, led South Africa to bring allegations to the International Court of Justice that Israel’s actions were "genocidal in character" (3) and the UN special rapporteur on human rights in the Palestinian territories to state that there were reasonable grounds to believe that Israel is committing genocide in Gaza (31).

Displaced and unaccompanied children have distinct needs that too often go unrecognised by both humanitarian agencies and governments. Also critical is the protection and rebuilding of the Gazan health and education systems. Health workers urgently need essential medications, equipment, and other supplies, particularly for children. International medical institutions and professional networks can help facilitate the safe evacuation of children in need of specialised medical care. These networks can also help students and health professionals continue their education so that they will be able to provide crucial health services in Gaza for years to come. Every university and hundreds of schools in Gaza have been damaged, and more than 600 000 children have been out of school since the October attacks. Without immediate protections for schools and support for reopening, education—a critical child right—will be neglected with long term damaging consequences (32, 33).

Third, the global ability to monitor the consequences of war urgently needs to be strengthened. More than 10 months into the conflict, there is still no definitive information on the number of civilian casualties. Although the Gaza Ministry of Health remains the primary source for casualty figures, the infrastructure for assessing casualties has been damaged and there are undoubtedly many killed yet to be discovered (5). Beyond the need for political or legal accountability, accurate information on those who have died is an essential, if tragically belated, way to value them in life. This is of special importance for children, who may have left behind little evidence of their existence other than in the hearts of their families. Currently, documentation relies on a patchwork of UN, academic, non-governmental, and local sources, often with unclear methodologies and political agendas.

Various new technologies could contribute to the assessment of the humanitarian impact of war. These include advanced remote sensing capabilities, modelling strategies, and artificial intelligence—technology currently used to fight a war (34)—should be purposefully and ethically harnessed to assess infrastructure damage and document casualties and humanitarian needs (35). Innovative statistical techniques have been used with existing datasets to estimate excess deaths associated with the armed conflicts in north east Nigeria and Somalia (36, 37). Remote monitoring and artificial intelligence may also contribute to improved systems for assessing the impact of war (38, 39). Academic and non-governmental organisations have pioneered new digital strategies to uncover or confirm military operations and attacks on civilians and civilian infrastructure. These emerging capabilities could contribute to a more fully integrated and authoritative global system for rapidly and accurately assessing the human cost of war.

Lastly, a focus on the humanitarian needs of children in war must not be interpreted as diminishing the humanitarian claims of all adults, soldiers and civilians alike. Indeed, children’s claims have much in common with adult claims. Nevertheless, there has been a long tradition of perceiving and addressing the plight of children as being shaped by a distinct moral, sentimental, and material character. The modern origins of child protections in war were first advanced by the Save the Children movement, which opposed the British blockade of Germany during and after the first world war that contributed to widespread child starvation in eastern Europe (40). Focused attention on the distinct needs and rights of children was also actively pursued during the decade leading up to the adoption of the UN Convention on the Rights of the Child in 1989.

Given the plight of children in Gaza, Ukraine, Sudan, and the many other countries in which children are exposed to violent conflict, we call for a renewed global commitment to the distinct needs and rights of children in crisis. This will require building stronger coalitions and a unified public voice to confront the marginalisation of children in our humanitarian strategies and the impunity with which the perpetrators of humanitarian violations continue their assaults. Although no single meeting or strategic plan can deal with the nature, scope, and urgency of this challenge, a pragmatic, global summit that meaningfully engages affected communities and other essential actors could prove useful in building a sustained, re-energised movement (41). The summit should urgently review existing UN resolutions and guidance and focus on amendments and implementation strategies that ensure protection and evacuation of children from conflict zones. The status quo is unacceptable. The statistics from Gaza not only provide a harsh, synoptic judgment on an enfeebled global morality but should lay the foundation for a renewed humanitarian commitment to the needs and rights of children experiencing the horrors of war.

Footnotes

Contributors and sources ZAB has extensive experience of working in conflict and humanitarian settings and founded the BRANCH (Bridging Research and Action for Women and Children in Conflict and Humanitarian Settings) consortium in 2016. GBD has experience of working with deprived families in south east Asia and PHW is an expert in child health in complex political and security environments and is the juvenile care monitor for the US Federal Court overseeing the treatment of migrant children in US border detention facilities. ZAB and PHW conceptualised and designed this analysis. GBD carried out searches, compiled data, and synthesised the evidence. ZAB led the interpretation of evidence and the writing of this paper with substantial contributions from GBD and PHW. All authors approved the final article for submission. Data were retrieved and compiled from public and electronically available sources. ZAB is the guarantor.

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This article was originally published on the BMJ.