Child growth and armed conflict

Abstract Background During armed conflict, the non-combative population, and particularly children, are susceptible to the effects of conflict from a variety of perspectives; psychological stress, loss of food and resources, loss of accommodation, occupation, income, death of family members, etc. The Lancet recently published a special issue entitled ‘Maternal and child health and armed conflict’ concluding that the ways in which health can be affected by conflict are protean but systematic evidence is sparse, whatever evidence exists is localised and of low to moderate quality, and that data on adolescents are sparse to non-existent. Whilst this may be true of the challenging environments of conflicts in developing countries, historically recent conflicts in Europe provide an alternative viewpoint that is frequently aired in the Auxological literature but is virtually unknown and/or unrecognised in health settings. Methods The current paper summarises three previously published studies based on repeated cross-sectional child growth surveys in London, Oslo, and Stuttgart covering the years of the Second World War. Taken together these studies provide extensive evidence of the response of children to armed conflict in the context of secular tends in growth of children living in industrialised nations during the twentieth century. Conclusions The conclusions to all three studies may be summarised, with regard to children in industrialised nations, as: (1) armed conflict adversely affects human growth and health, (2) armed conflict affects all age groups but adolescents more so, (3) all age groups recover from poor growth as conditions improve in relation to post-war health and welfare programmes, (4) pre-war differences in size between SES groups diminish during post-war recovery when accompanied by nutritional, welfare and reconstruction programmes.

the purpose of including "25 battle-related deaths" identifies the conflict as being a "serious conflagration" and in terms of research, makes it much less likely that such conflicts will be overlooked.
Using this definition, it is evident that there has never been a time when armed conflict is not occurring somewhere in the world.whilst the first half of the twentieth century was dominated by the 'world wars ' of 1914-18 and 1939-45, armed conflict was omnipresent throughout the century.For instance, never less than 40 countries worldwide were involved in armed conflicts between 1989 and 2018 (Uppsala conflict Data Program 2020).

Outcomes of armed conflict
the non-combative population are susceptible to the effects of conflict from a variety of perspectives; psychological stress, loss of food and resources for daily living, loss of accommodation, occupation, income, death of family members, etc. (Bendavid et al. 2021).whilst all members of the population suffer to a greater or lesser extent from the result of armed conflict, children are arguably the most vulnerable and suffer the most.long term outcomes of early experiences extend into adulthood (e.g.Merrick et al. 2019) with major influences on human behaviour and health and wellbeing at the family, community, and national level (e.g.Naicker et al. 2022).children thus form a specific and special group for investigation of the effects of armed conflict on their health and wellbeing.Since human growth and development have been shown to be sensitive to adverse environmental conditions (e.g.Kang Sim et al. 2012) it is pertinent at this time to review the evidence for the effect of armed conflict on their growth.
in February 2021 the lancet published a series of papers under the title 'Maternal and child health and armed conflict' (Bendavid et al. 2021).the key messages resulting from the reviews were that; the ways in which health can be affected by conflict are protean but systematic evidence is sparse; existing evidence links conflict to malnutrition, physical injuries, acute and infectious diseases, poor mental health, and poor sexual and reproductive health; however, aside from malnutrition, the evidence is typically localised and of low to moderate quality; finally, data on adolescents are sparse to non-existent.whilst these messages may be to some extent self-evident from the nature of conflict, the pertinent auxological literature from industrialised nations provides evidence in relation to adolescents that is both relatively rich and generalisable across countries.
Since the early years of the nineteenth century the auxological literature has been a source of data relating to the human growth outcomes of armed conflict in the developed world but, in relevant circumstances relating to the nature of the conflict and the age range of children affected, these data may be relevant to the developing world. in part the presence of growth data for analysis in industrialised nations was due to the fact that various cities in europe initiated programmes in community health that involved using child growth as an indicator of health.Regular studies of the physical growth of representative samples of their urban child populations were undertaken in order to monitor their health and wellbeing.Human growth had been recognised as a sensitive indicator of child health since the middle of the eighteenth century when poor growth was documented in children of the lowest socio-economic groups in comparison to better growth in their wealthier peers (tanner 1981).
three contemporary european cities lend themselves to direct comparisons of the relationship between human growth and armed conflict: london, Oslo, and Stuttgart.these cities are matched historically, geographically, and by the nature of the armed conflict they experienced i.e. the Second world war of 1939 to 1945.
it is characteristic of war studies that there is a great deal that we don't know about the children of war e.g.how long they lived in the area, if they left and if so for how long, their personal experiences of injury and loss, any details of SeS apart from area in which they lived and perhaps type of school, and so on.So the available data is not perfect but, with sensitive interpretation and an appropriate focus, still serves to provide an insight of the way in which human growth responds to armed conflict.

London
Data on the growth of london children had been collected since 1904 under the direction of the london county council (lcc).the surveys were not at regular intervals and their timing appears to have been dictated by local government concern over child health status. the survey of 1904-1905 was, for example, prompted by the 'inter-Departmental committee on Physical Deterioration' which was concerned over the 'lack of fitness' of army recruits.the regular medical inspection of schoolchildren was introduced under the education Act of 1907 which led to the development of a growth 'standard' to cover 7 to 14 years of age.these standards remained in use until the lcc decided in 1935 that all elementary schoolchildren should be weighed and measured at 6 monthly intervals (cameron 1977).whilst world war 2 prevented any large-scale surveys there were surveys of smaller areas in 1942and 1943(Daley 1944) ) and full periodic measurements were resumed in 1948 (Scott 1961).these six-monthly surveys were used for the published data from 1942 to 1950 (london county council 1950) and, because of policy changes within the lcc, ad hoc surveys were organised from 1954 to 1967. the resulting data on the growth of london schoolchildren during the twentieth century was therefore in response to perceived health concerns and the result of well-intentioned local government decree.the availability of data from frequent reports of the Medical Officer of Health (MoH) for london allowed cameron (1977) to undertake an analysis of the growth of london schoolchildren concentrating on the 1966-67 survey but relating the results to all previous surveys.thus a description of the secular trend in the growth status of london schoolchildren was created that covered the years of both peace and armed conflict from 1904 to 1967.these cross-sectional surveys provide a continuous record of the changing growth status of the children of london in response to changing environmental circumstances (cameron 1979, 1980; tanner and cameron 1980).
the Second world war (ww2, 1939Second world war (ww2, -1945) ) was of particular interest because london was the subject of widespread bombing during the london Blitzkrieg ('lightening war') from 7 th September 1940 to the 11 th May 1941. the bombing attacks by german air forces were sustained and caused widespread destruction.From 7 th September to 13 th November 1940, for instance, the 'Official History of world war 2′ (collier 1957) records that 18,291 tons of bombs fell on london in 71 raids on 56 of the 57 days and nights between those dates.Of course the targets for those raids were not general areas of the city but were aimed at areas of manufacture and economic importance such as the docklands, and the city of london itself (an area of 1 square mile within the country of london). it is also within those areas that the lowest socio-economic conditions were to be found.the county of london contained 14 administrative areas including the city of london, described as Boroughs.these boroughs also incorporated Area Health Authorities (AHA) that monitored and managed the health and wellbeing of the local inhabitants.the MoH of the london county council worked with the various AHA representatives to carry out the repeated health assessments and checks on the growth status of children within the county.cameron (1979) demonstrated the secular trend in both height and weight that characterised the growth of london schoolchildren from 1908 to 1967.Up until the outbreak of ww2 the trend was consistently positive in terms of magnitude per decade but slowed between 1938 and 1949 and accelerated again from 1949 onwards.these trends were age related in that prior to adolescence the changes were between 1 and 2 cm.decade −1 and 1 and 2 kg.decade −1 throughout the 1950s but from early adolescence, at age 10 onwards, there was a clear acceleration in the trend for adolescents in the 1949-1959 decade peaking at 14.5 years in boys and 12.5 years in girls at about 4.5 cm.decade −1 and 5.3 kg.decade −1 for the former and 3.2 cm.decade −1 and 3.5 kg.decade −1 for the latter (cameron 1977).Both trends in height and weight were greater for the 1949-1959 decade than in any previous decade demonstrating perhaps a growth response to the alleviation of the direct privations of the war years, the rationing of food with special reference to childhood diets, and free health care following the establishment of the National Health Service in 1948.the improvement in environmental factors affecting growth following the war was, of course, a gradual phenomenon.Rationing of food, for example, continued until 1953 but, with due preference being given to the diets of children and pregnant women, it was generally accepted that their diet during the later years of the war and during post-war rationing was preferential to pre-war and early war-time periods (Davidson 1944).indeed Davidson (1944) reports that "…during 1941-42, when the amount of food reaching the consumer was at its lowest level, a deterioration in the nation's nutritional status had begun.thus Milligan's surveys [surveys by the London MoH] of the health of elementary school children in 1941-42 showed a reduction in the average gain in height and weight and a lowering in the powers of endurance as compared with pre-war tests.His findings for 1942 and 1943 showed a progressive improvement." (Davidson p 438).So, the early war years when nutrient availability was severely restricted had a negative effect on child growth but scientifically based rationing and preference to the young provided an effective platform for a degree of catch-up growth to occur, particularly amongst adolescents.
the National Health Service (NHS) was founded in 1948 and provided free healthcare for all at the point of delivery.this idea of a national health service was first mooted in the early years of the war by the economist Sir william Beveridge.in a 1942 report he reimagined the role of the state in a post-war nation, setting out to combat the five "great evils" of society: want, disease, ignorance, squalor and idleness.(https:// wellcomecollection.org/articles/wyjHUicAAcvgnmJi2018).the core of this vision was the establishment of a national health service funded from taxation that was realised by the post-war labour (socialist) government of Prime Minister clement Attlee and the specific work of the Minister of Health, Aneurin Bevan. the effect of free health care on child health was dramatic in that infant and child mortality fell considerably faster in the 1950s than in the previous two decades.
the publication of the tonnage of high explosive (He) falling on each Health Division of london, in collier's 'Official History of world war 2′ (collier 1957), the local government organisation of london into Boroughs and AHA allowed an analysis of the relationship between area of residence, tonnage of He and the heights and weights of the child population resident in those AHAs. in 1949 there was a significant trend (p < 0.05) for children living in the poorest AHAs to receive the most He and to be shorter and lighter.By the time of the 1966 survey that relationship had reversed so that children living in the war-time poor areas that had received the most He were now the tallest and heaviest of london children.So, whilst the children living in poor heavily damaged areas demonstrated poor growth during and immediately following the war they appeared to show a degree of catch-up growth in the following years that was particularly marked during adolescence (table 1). in summary, the smallest and lightest children in london received the greatest amount of He, but within 5 years that relationship had weakened, within 10 years it was non-existent and after 15 years it had reversed.in addition, the size difference between socio-economic groups designated by area of residence also diminished from 2.4 cm and 4.6 kg in 1949 to 1.1 cm and 2.4 kg in 1966.So, whilst armed conflict targets those living in areas of high population density and low SeS, recovery, characterised by relatively greater growth rates, appears to favour those from areas of most damage.Similar to the situation in london the growth of children during the war years in Oslo was closely connected to the availability of adequate nutrition.galtung- Hansen (1947) and Strøm (1948) demonstrated a reduction in average caloric intake, from 3475 kcal (14 530 kJ) in 1939 to a minimum of 2700 kcal (11290 k J) in late 1944 and early 1945 primarily due to a reduction in fat rather than protein.Unlike london which, of course, was not occupied by invasion forces, the availability of adequate nutrition was not improved until after the occupation from 1945 onwards.the results in terms of height can be clearly seen in Figure 1 and are more dramatic for mean weight.
Post-war analyses of socio-economic (SeS) differences are complicated by proxy measures of SeS e.g.place of residence or type of school, but are consistent in their outcomes.Similar to the london data, there is a reversal of the social differences for weight and age at menarche.the analysis is hampered by the lack of reliable information about nutritional differences between children from the different SeS groups and therefore not allowing Brundtland et al. (1980) to make firm conclusions on the reasons for the reduction in SeS differences.However, it is clear that before the war, children from higher strata were taller than children from lower strata, but this difference practically disappeared by the 1970s.children from the higher strata weighed more until about 1955, but later those from the lower strata weighed markedly more, especially during adolescence.

Stuttgart
Stuttgart was virtually destroyed by the allied bombing programme that took place from 1942 onwards but that was particularly heavy during 1945.the city endured 18 large-scale Figure 1.oslo girls mean heights 1920 to 1975 by age (Brundtland et al. 1980).
between March 1942 and February 1945, of approximately 500 bombers on each occasion, during which 21,353 tons of bombs were dropped on the city by American and British air forces.
From 1926 onwards Dr Maria Schiller was responsible for twice yearly data on the growth of Stuttgart schoolchildren aged 6 to 12 years.the voluminous data obtained were presented by Howe and Schiller in 1952 (Howe and Schiller 1952) although there had been previous publications of earlier analyses in 1927, 1935, 1948and 1949(see Howe and Schiller 1952 for references).the data relate to children by school of which there were four types accommodating, to all intents and purposes, different SeS levels; volksschule, Mittleschule, grundschule, and Oberschule. the Oberschule or higher school were attended for four years after grundschule (grade school) in preparation for university entrance with consequently higher SeS children. the Mittleschule (middle school) prepared children for technical schools in which there was a "tendency towards higher incomes." the volksschule (people's school) and the grundschule (covering the first 4 years) were the basic elementary schools attended by children from families of all income levels.children who were not expected or could not afford to go beyond a secondary education stayed at the volksschule through their 14 th year of age. the data on the heights and weights of these children provide, therefore, the opportunity to investigate the extent and pattern of secular changes and the SeS differences in Stuttgart children from the 1920s onwards.
the data are presented by Howe and Schiller (1952) in the form of graphs similar to those of Brundtland et al. (1980) i.e. in mean heights and weight for each age group over time (Figure 2). the graphs also demonstrate a similar pattern of secular trends in response to environmental stress.Howe and Schiller emphasise a number of points; there are differences in mean heights and weights between school type with the lower SeS volksschule pupils being shorter and lighter than the higher SeS Oberschule pupils.when nutritional conditions improve the lower SeS volksschule pupils respond more acutely than the Oberschule pupils.whilst a positive secular trend continued throughout the twentieth century there were interruptions coinciding with the years of war (1914-1918 and 1939-1945).Following ww2 there was an increase in heights and weights of all children of all ages.
Stuttgart benefitted from a variety of post-war recovery initiatives primarily from the 1947 Marshall Plan, also known as the "european Recovery Program, " that was extended to include west germany in 1949.this involved $13 billion of economic and technical assistance (c.$144 billion in 2022) allocated to western europe between 1947 and 1952.Between those years west germany received loans which totalled $1.45 billion (c.$16 billion in 2022).these benefits had a direct effect on living standards and inevitably on the growth of children.
Howe and Schiller (1952) concluded that "children, and particularly adolescent children, are measurably affected in times of stress as the result of environmental changes, including actual food shortage, or as the result of economic stress.they exhibit a retarded rate of increase in height and weight.the increase in weight may even be less than that expected for the particular height attained.the failure to grow at an expected rate may be due to a simple lack of sufficient food, failure to eat, to specific inadequacies of the diet or to a combination of these factors….the increased morbidity that exists during periods of war and following a war is often ascribed to food without taking into consideration the poverty, stress and poor hygienic conditions which are also associated with such periods." (Howe and Schiller, p57).

Discussion
the effect of armed conflict on the growth of children living in three european cities experiencing widespread deprivation and destruction as a result of armed conflict during the Second world war have been demonstrated by analyses of data on growth in height and weight conducted in london by cameron (1979,1980), Oslo by Brundtland et al. (1980), and Stuttgart by Howe and Schiller (1952).these cities are matched historically, geographically, and by the nature of the armed conflict they experienced i.e. the Second world war of 1939 to 1945. in addition, all three cities experienced post-war initiatives to improve the physical environment in comparison to pre-war conditions.whilst the children in these cities shared a common experience physical and psychological trauma, they also experienced post-war improvements in the supply and availability of nutrients and in the physical environment in which they lived through health, welfare, and housing programmes.
these results must, of course, be framed within the context of data on child growth, and by implication health, against the background of cities involved in armed conflict and the logistical problems involved in data collection.in any arena of conflict the collection of data on child growth that is free from the constraining effect of social and physical disruption caused by the conflict is rare.the lives of participants are disrupted by local conflict erupting and subsiding often unpredictably requiring alterations to clinic attendance and set data collection times.However, it is almost a truism to state that those responsible for growth studies in such environments invest considerable time and effort in ensuring that the best possible data collection procedures are followed (Richter, 2022).thus these ubiquitous findings from three cities affected by armed conflict stand as reliable records of the growth of children before, during, and after the most intensive and widespread armed conflict in the history of europe.
As stated earlier, there is a great deal that we don't know about the children of war in terms of length of residence, the extent and duration of evacuation, their personal experiences of injury and loss, and detailed SeS measures apart from area of residence and sometimes type of school.So, we can only make general statements, but the ubiquitous nature of the outcomes adds power to those statements.
the key contributions from these studies in industrialised nations may therefore be summarised as: (1) armed conflict adversely affects human growth and health, (2) armed conflict affects all age groups but adolescents more so, (3) all age groups recover from poor growth as conditions improve in relation to post-war health and welfare programmes, (4) pre-war differences in size between SeS groups diminish during post-war recovery when accompanied by nutritional, health, welfare, and reconstruction programmes.
in terms of the lessons that might be learned from these outcomes and the current Ukrainian-Russian conflict, it is difficult to predict the extent of both short and long-term damage to child health and growth.the current theatre of war is set eight decades after the last major european conflict and differs dramatically due to advances in technology, communication, social welfare, health, and ease and convenience of travel, but not in terms of the direct and life changing experience of armed conflict.Ukraine is classified by the world Bank as a low Middle-income country (lMic) but there is little doubt that the war with Russia will have a deleterious effect on this status.in 2017 Ukraine launched a National Health System (NHSU) and an Affordable Medicines Programme which provided access to medical care and treatment for the whole population.95% of the population rely exclusively on the NHSU for health care and the ongoing war with Russia has put greater stress on a system that was already under stress.growth reference charts for the Ukraine published in 2018 reflect average heights and weights of children aged 7 to 18 years that are just below or on the wHO 50 th centile and adult heights of 178.4cm for men and 164.2cm for women (ludvigsson and loboda 2022).Ukrainian men and women had experienced significant secular trends in height in the decades leading up to the millennium with men rated 21st and women 10th in the world for height in 1996 (NcD Risk Factor collaboration 2016).A recent systematic review of the health of Ukrainian children by ludvigsson and loboda (2022) highlighted that prior to the current conflict, in 2019, "under-5 mortality was 8 per 1000 live births in Ukraine.Underweight and adverse childhood experiences, including child abuse, were frequent compared to other european countries, while childhood obesity seemed less common.Alcohol consumption was common in women of reproductive age, including during pregnancy, risking foetal alcohol syndrome.Neonatal screening programmes provided low coverage.vaccine hesitancy was common and vaccination rates were low.Other concerns were measles, Hiv, antibiotic resistance, and multi-resistant tuberculosis.Many children [were] expected to suffer from psychological and physical trauma due to the war." (ludvigsson and loboda 2022, p. 1341).UNiceF (2021) provides a concerning review of child health in the Ukraine prior to the current conflict with figures for infant (7%) and under-5 mortality (8%), childhood mortality (5-14 years) (2%), percentage of low birth weight (6%) and stunting from 0-4 years of age (16%) all amongst the worst in eastern europe.these figures are, not surprisingly, accompanied by a low life expectancy of 73.2 years compared to more than 80 years in western europe.it is clear that the Ukraine, with a national health and wellbeing profile that is amongst the worst in eastern europe will need comprehensive health, welfare, and rebuilding programmes.the growth and development of children experiencing the armed conflict is likely to be reflected in a reduction in growth rates which can recover if the post war programmes are instituted widely and rapidly.to monitor these phenomena it is important to establish appropriate surveillance models to identify those children most in need.So, the Ukraine will start post-war recovery from an historical low point but one which may be not too far removed from equivalent data in western europe between the wars. in the UK, for instance, infant mortality was 7% in 1923, falling to 5.4% in 1940 and rising to 6.3% in 1941, then diminishing to 4.9% in 1945 and 3.1% by 1950 (https://www.statista.com/statistics/281501/infant-mortality-rate -in-the -unitedkingdom/).childhood mortality rate fell from 8.8% to 7.6% between 1935 and 1940 in the UK and was at 4.4% by 1950 (https://www.statista.com/statistics/1041714/united-kingdom-all-time-child-mortality-rate/).So even allowing for the Second world war these vital child health statistics were virtually halved following the initiation of post-war recovery programmes such as free health care.whilst the situation in the Ukraine is dire and showing no current signs of improvement previous experience of other european countries at a higher stage of development is that post-war recovery is inevitable as long as the developmental indicators pertaining to child health and wellbeing can be improved.
given these outcomes it is pertinent to return to the key messages from the lancet (2021) special issue (Bendavid et al. 2021) and emphasise that the current comparison and the previous review are in different theatres of armed conflict.the lancet review specifically concentrates the effect of various types of armed conflict children in a variety of developing countries, whilst the current review focuses on a specific armed conflict in developed countries in a specific historical context.Both comparisons support the fact that the ways in which health can be affected by conflict are protean, but the latter provides considerable systematic evidence across three cities in western europe that is abundant rather than sparse.the existing evidence that links conflict to malnutrition, physical injuries, acute and infectious diseases, poor mental health, and poor sexual and reproductive health may be obtained from 'local' sources but can be combined across research sites with significant common factors matched by historical time, geographical position, and war zone.Finally, data on adolescents in developed countries is clear in demonstrating that whilst all children are affected by the physical, social, and emotional deprivations of armed conflict, adolescents demonstrate responses of greater magnitude.

Oslo
the occupation of by Nazi germany during the Second world war began on 9 April 1940 and lasted until May 1945.like london, the growth of the children of Oslo had been assessed at regular intervals as part of the city school health system lead by carl Schiøtz, who published a series of papers between 1918 and 1933 describing the growth of Oslo schoolchildren (e.g.Schiøtz 1923).From 1918, Oslo schoolchildren had their height and weight measured annually and every five years the data from all schools were centralised for analysis.Brundtland et al. (1980) took Schiøtz's early work further and published an analysis of height and weight covering the years 1920 to 1975 including an analysis of socio-economic differences.their article contains graphs illustrating the growth in height and weight of each age group from 8 to 13 years and at 18 years.the graph depicting girls' heights is reproduced as Figure 1. the pattern of the changes in height is similar for girls' weights and for both height and weight in boys.the positive secular trend is clearly seen prior to the years of Nazi occupation and then, in both sexes and all age groups, lower mean values are apparent for the years 1943 and 1945.thus the positive trend was interrupted during the years of occupation but values from 1947 onwards demonstrate a resumption of the positive trend.Note this doesn't mean that children's heights or weights were diminished by the war, but that the growth velocities of, for example, the 11-yearolds from 1940 to 1945 were less than the growth velocities experienced by 11-year-olds from 1935 to 1940.So their mean height at 12 years appears to be less than the pre-war values.the values in 1947 and 1950 are more in concert with the pre-war values although the clear positive secular trend in both height and weight prior to the war are clear but not dramatic in the post-war years.

Figure 2 .
Figure 2. mean heights and weights of stuttgart girls 1915 to 1948 (Redrawn from data in Howe and schiller 1952) nB: the figures are the average of the measurements for the half year, i.e. 6-7 represents the average of observations on children 6 to 6½ and 6½ to 7 years of age when measured Howe and schiller (1952).

Table 1 .
spearman's correlations for the tonnage of High Explosive against the Area Health Authority ranking for height and weight1949 -1966  (Cameron  1977)).