Taking care of children in the war period – Daniel Martínez Garcia [Keynote Talk]

Speaker: Daniel Martínez Garcia (Switzerland), humanitarian paediatrician with more than 20 years at Médecins Sans Frontières (MSF). He has worked in over 20 settings, including earthquakes and, above all, armed conflict. In her introduction, the chair, who first worked with him on her own first MSF mission in 2017, described him as “the lighthouse in Geneva” for field paediatricians.

He opened by noting how rarely child health in war reaches a plenary stage. He spoke in a personal capacity and declared no conflicts of interest.

The big picture: a short, fragile golden age

• For about 300,000 years, 40–50% of children died before adulthood, across every civilisation studied.

• Within the last 200 years, under 0.07% of human history, global child mortality has fallen below 4%. Vaccination, antibiotics and the industrial-era demographic transition drove this.

• “Childhood” as a protected category is also a recent social construction. Paediatrics as a profession exists because children started to survive. The goal now is for them to thrive, not only survive.

• Country curves for Nigeria, DRC, Ethiopia, Somalia, South Sudan, Rwanda, Afghanistan and Sudan show steep declines interrupted by sharp spikes back to pre-industrial mortality during wars. These gains can reverse very quickly, as seen in Syria, Libya, Venezuela and Ukraine.

Children in conflict: the numbers

• About 1 in 5 children live in conflict zones, and around 50 million are displaced by conflict and violence.

• Their risk of dying before age 5 is about 3× higher. Roughly half of global under-5 mortality occurs in fragile or conflict settings. India, which is large but stable, is the main outlier.

• Indirect deaths outnumber direct trauma deaths about 3:1. Children die of diarrhoea without clean water, of pneumonia when there is no electricity and therefore no oxygen, and of vaccine-preventable diseases when systems collapse.

• Excess infant mortality persists for more than 8 years after the fighting stops.

• State-led sieges that restrict food and medical supplies to civilians have returned, citing Ukraine, Sudan and the Palestinian territories. They violate international humanitarian law and drive severe acute malnutrition.

• Chronic disease, disability and mental health are often overlooked, even by humanitarian organisations (“we come as cowboys for emergency care”). Most crises last years.

Take-home for neonatology: the perinatal period is the highest-yield intervention

• About 47% of under-5 deaths occur in the neonatal period, more than 2 million deaths a year, concentrated in conflict settings.

• In conflict settings, the most cost-effective technical intervention is to protect the mother–newborn dyad: safe delivery care, essential newborn care and no mother–baby separation.

• Where full newborn care isn’t feasible, he proposed a minimum package:

  • water and sanitation

  • food access

  • routine vaccination

  • shelter, protection and safety

  • education, which is usually not classed as an emergency service and is often forgotten

• Oxygen saves lives. In one MSF clinic, introducing paediatric intensive care and then reliable oxygen brought respiratory-infection mortality close to zero. He added a personal example: his daughter’s bronchiolitis needed only oxygen for three days, which would have been impossible without electricity.

• Ebola in DRC: a very large current outbreak, with more than 9,000 cases reported, is receiving little attention. In the cohort shown, 24 of 30 children died, a mortality of 60–80%. Contributing factors include biology, the absence of paediatric therapeutic research for a disease that rarely affects rich countries, and the harm of separating children from caregivers.

Children are not passive victims

• Children have agency, diversity and voice, and they can tell us what they need. He warned that “resilience” can mask the long-term consequences of trauma, particularly in the first 1,000 days.

• He contrasted an anonymous, de-identified fundraising image of a war victim with a 17-year-old girl from El Fasher, Sudan. She chose to share her name, her story and a poem about her lost childhood and her hope that other children in her country will no longer live in fear. Dignity-respecting representation strengthens empathy.

Calls to action for paediatricians

1. Equal empathy for all children. He pointed out the gap in Switzerland: thousands of Ukrainian children were received, versus about 100 Palestinians granted refugee status. He called it appalling.

2. Protect healthcare. Health workers and facilities used to be hit by mistake. In the last 20 years they have become open targets.

3. Don’t take part in medical age assessment for legal status. There is no scientific evidence base. Clinicians are being instrumentalised to remove protection from young people, and nationality affects how they are treated.

4. Professionalise humanitarian paediatrics. Treat it as a career path rather than “tourism”, go to learn from local health workers, and know your context. Tropical paediatrics is not a substitute.

5. Treat refugee and migrant children in your own clinic as individuals. Don’t treat them as threats to be screened for every disease. Listen to what they need.

6. Bear witness. Speaking out about rights violations is medical advocacy, not activism, and he urged clinicians not to hide behind neutrality. This applies within your own institution even if you never deploy.

7. A ceasefire is the most cost-effective child-health intervention of all.

Closing message: The era of children surviving and thriving is a blink in human history, with no guarantee it will last. It also shows what collective action can achieve. Whatever you do may seem insignificant, but it is important that you do it.

Disclosure: This is an AI-assisted summary of the session, generated from a recording made by our team in attendance. We believe it is as accurate as our own notes would be, but please refer to the speakers’ original work before applying anything in clinical practice.