Journal of Forensic and Legal Medicine 34 (2015) 1e4
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m
Original communication
Childhood casualties during civil war: Syrian experience Adnan Çelikel a, *, Kenan Karbeyaz b, Bekir Kararslan c, M. Mustafa Arslan a, Cem Zeren a a
Mustafa Kemal University, Medical Faculty, Department of Forensic Medicine, Hatay, Turkey Council of Forensic Medicine, Eskisehir, Turkey c Gaziosmanpas¸a University, Medical Faculty, Department of Forensic Medicine, Tokat, Turkey b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 16 February 2015 Received in revised form 16 April 2015 Accepted 30 April 2015 Available online 12 May 2015
In war areas a lot of children die as well as adults. According to UNICEF, almost 2 million children have died in the wars took place in the last 10 years. In this study, we aimed to evaluate demographical data and injury characteristics of Syrian children who were wounded in Syria Civil War and died while being treated in Turkey. Postmortem examination and autopsy reports of 985 forensic deaths from Hatay -a Syrian neighborhood city of Turkey-between January 2012 and August 2014 were analyzed retrospectively. Among 763 Syrian people who were wounded in the war and died while being treated in Turkey, 140 cases (18.3%) who were younger than 18 years of age were taken into the scope of this study. Among those cases 77.9% (n ¼ 109) were male and 22.1% were female. Median ages of female cases are 14 (minemax: 2e18) and median age of female cases are 9 (minemax: 1e18). Frequency distribution is highest between 13 and 18 years of age (n: 71, 50.7%). In 70% (n: 98) of cases, cause of death is bombing and shrapnel injuries, 13.6% (19) of them were killed by gunshot wounds. According to injury sites most of the injuries were reported to be on multiple body parts (54.3%, n: 76) and only head and neck injuries (%30). Cause of death was intracranial bleeding and cerebral parenchymal injury in most of the cases (n: 66, %47.1) followed by vascular damage with external bleeding (n: 15, %10.7) and internal organ damage with internal bleeding (n: 15, %10.7). The cases had very high level Abbreviated Injury Scales and Injury Severity Sores. In conclusion, a lot of children have died in the Civil War of Syria. Their average abbreviated injury scale and injury severity score values reported very high. Children that we evaluated were mostly died of head and neck injuries predominantly caused by bombing attacks and Autopsies of them revealed fatal intracranial hemorrhages and parenchymal injuries. © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Civil war Childhood deaths Forensic medicine
1. Introduction Wars have important effects on human lives. While ratio of civil victims to total deaths in World War I were about 14%, it reached 90% in 1990's.1 Since the beginning of the Syrian Civil War over 130,000 people have died, Nearly 4 million people have fled the country and become refugees of which 1,738,448 came to Turkey.2 In war areas children are seriously affected too.3 A child is any human being below the age of eighteen years, unless under the law
* Corresponding author. Tel.: þ90 326 229 10 00; fax: þ90 326 245 56 54. E-mail addresses: [email protected] (A. Çelikel), drkenankarbeyaz@ hotmail.com (K. Karbeyaz), [email protected] (B. Kararslan), [email protected] (M.M. Arslan), [email protected] (C. Zeren).
applicable to the child, majority is attained earlier.4 According to UNICEF It is estimated that; about 2 million child have died, 4e5 million have been wounded and 12 million lost their homes in the wars that took place in the last 10 years.5 Hatay is a Syrian neighborhood province of Turkey. City Center Antakya where main hospitals are located is 60 km's away from the Syrian border. Many wounded people from Syria have been being treated here for nearly four years because of the civil war in Syria. The wounded refugees evacuated from the war zone for treatment who subsequently died here are considered as legal cases since they died in Turkey. In this study, we aimed to evaluate demographical data and injury characteristics of Syrian children who were wounded in Syria Civil War and died while being treated in Turkey.
http://dx.doi.org/10.1016/j.jflm.2015.04.021 1752-928X/© 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
2
A. Çelikel et al. / Journal of Forensic and Legal Medicine 34 (2015) 1e4
2. Material and method
Table 2 Causes of injury.
In our country postmortem examination and autopsy is performed for all legal deaths including caused by war related deaths. The data were collected retrospectively from total number of 985 autopsy records held by Ministry of Justice at Antakya Court House, between January 2012 and August 2014. Autopsies done to Syrian people who were wounded in the war and died while being treated in Turkey were 763 in total. Among them 140 (18.3%) who were younger than 18 years of age were taken into the scope of this study. Information related to incidents is obtained from hospital records which were taken from the families and relatives of the victims. Each case were evaluated according to their age, sex, injury method, injury regions, Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) which was calculated according to the severity of injury of body parts head, neck, face, chest, abdomen and extremity.6 The scores were rated by two forensic medicine specialists together (A.Ç&C.Z). Cases that died of natural death were excluded from the study. Obtained data are analyzed by SPSS (Statistical Package for Social Sciences) for Windows 13.0 Software and Mann Witney U test is performed. 3. Results Of all cases 77.9% (n: 109) is male and 22.1% is female. Median ages of male cases are 14 (minemax: 2e18) and median age of female cases are 9 (minemax: 1e18) (Table 1). Frequency distribution is highest between 13 and 18 years of age (n: 71). In 70% (n: 98) of cases cause of death is bombing and shrapnel injuries, 13.6% (n: 19) of them were killed by firearm bullets. Deaths because of blunt force injuries caused by hitting to hard surfaces, collapse of buildings and foreign objects due to explosions constitute 19 cases. Four children died in car crash that occurred near battlefield or while escaping from there. Injury features examined during autopsy were related to: firearms, bombing and shrapnel injuries, burns, moving objects due to explosions, blunt force injuries due to imploding of buildings (Table 2). According to injury sites most of the injuries (54.3%, n: 76) were reported to be on multiple body parts. It was followed by only head injuries by 30% (Table 3). For most of the cases cause of death was intracranial hemorrhage (subarachnoid, subdural, epidural) with cerebral parenchymal injury which was followed by external bleeding and internal organ damage with internal bleeding (Table 4). Abbreviated injury scales of all cases are documented to be 3 and more than 41.4% (n: 58) of all is 5 (Table 5). Mean of injury severity sores is 41.52 ± 22.62 and according to injury regions the only significant difference of ISS score was found in multiple body region injuries when compared with other regions (Table 6). When comparing the cases according to gender and age there was no significant differences with type of trauma sustained, injured body regions by using Mann Witney U test (P > 0.05).
Cause
Number (%)
Gunshot wounds Bombing and shrapnel Blunt force injury Car crash Total
19 98 19 4 140
(13.60) (70.0) (13.60) (2.90) (100)
4. Discussion Armed violence in wars is a worldwide public health problem against humanity.7,8 Mostly young adults are killed in wars, as well as children and old people may be victims. It is reported that for the individuals between 10 and 24 years of age, 2.8% is dying because of wars.9 East Mediterranean countries are the places where the war caused deaths mostly take place.10 Reflections of the ongoing civil war strongly affects Turkey because of the neighborhood relations. The wounded people from Syria are being treated in Turkey especially in Hatay as a neighborhood city and some of them die here during their treatment. An important ratio of Syrian people died in our province was children (18.3%). Studies on casualties of Iraq War which started in 2003 showed civil casualties were far higher than military deaths. Most of the civilians were killed by bombing from air attacks and suicide bombers.11e13 In this study injuries were distributed mostly as multiple part and head injuries, death was mostly caused by bombing with shrapnel injuries. Those data show civilians are hit by bombardments (both from air and land) without any distinction from military targets. A study from Kosovo war reported: men died in the war were far more than women between 1998 and 1999. Same study showed the ratio of men and women killed in the war between 0 and 14 years of age were similar.14 It is thought that children deaths are increasing because they are unable to perceive the danger; they lack of knowledge about protection methods and can't escape. Additionally shrapnel injuries, house collapses and other car crashes occurred during escape caused by bombing of civilian settlements. According to the studies on Iraq War 14% of the people who are killed were children.15 By the start of war there was an increase in death of children in younger than 15 year of age.16 Another study showed, among the 22,066 Iraqi civilian victims demographically identifiable as men, women, or children, 9.7% were children (n ¼ 2146) and among 2146 child deaths 26.0% were identified as boys, 13.9% as girls, and others sex was unreported.12 It is reported that, 23% of all victims were civilians in Croatia war. Among this civilian 15.8% of them were children and 27.9% was woman.17 A study from Palestine reported 9% of injured people in the war was women and 12% was children younger than 14 years of age.18 Majority of the child victims were between 13 and 18 years of age (Table 1) In our study most of the child victims were male and -according to information obtained from families or relatives of the victims-none of them were fighters.
Table 1 Demographical data of cases.
Sex Male Female All cases
N (%)
Minimum
Maximum
Median
109 (%77.9) 31 (%22.1) 140
2 1 1
18 18 18
14 9 12
ISS
140
9
75
41.5 ± 22.6
Treatment period (day)
140
0
60
5.08 ± 8.7
Table 3 Distribution of injured body parts. Body part
Number (%)
Head & neck Chest & abdomen & back Extremities Multiple parts Total
42 17 5 76 140
(30) (12.10) (3.60) (54.30) (100)
A. Çelikel et al. / Journal of Forensic and Legal Medicine 34 (2015) 1e4
3
Table 4 Causes of death. Cause of death
Number
Intracranial hemorrhagea & cerebral parenchymal injury External bleeding Organ damage & internal bleeding Organ damage & complications Intracranial hemorrhage & internal bleeding Spinal fractures &respiratory paralysis Burns & complications Cerebral parenchymal & organ damages & internal, external bleeding Total a
Total (%)
Male
Female
50 11 14 10 12 1 7 4 109
16 4 1 3 6 e 1 e 31
66 (47.1) 15 (10.7) 15 (10,7) 13 (9.3) 18 (12.9) 1 (0.71) 8 (5.71) 4 (2.9) 140 (100)
Epidural, subdural, subarachnoid hemorrhage.
A study comparing casualties in early and late periods of Iraq War reported that, in late period of the war more casualties with fragment wounds, fewer gunshot wounds were reported.19 In our study most of the deaths were due to bombing and shrapnel injuries, deaths caused by gunshot wounds were quite a few. AIS and ISS values of casualties were very high (41.52 ± 22.62). We thought such high values are results of intensive use of bombings. To best of our knowledge, there isn't any study in the literature on childhood casualties in terms of injury types and properties. In a few studies in which injury sites are evaluated, it is reported that: injury ratios are similar according to body parts, head, neck, chest and abdominal injuries are more lethal than extremity injuries. One documented that most of the victims were lost in prehospital phase and in the first 30 min.20 Another study documented the most common injuries were involving the muscles and bones, followed by abdominal region, neural system, thoracic organs, and cardiovascular system.18 Past studies have not evaluated the injury pattern of children specifically. This the first study evaluating childhood injury patterns in war. In our study, mostly documented injury pattern were multiple body parts injury, followed by head injuries by. Due to direct and indirect effects of the war area there are several difficulties for determining the casualties.21 Syrian children who were wounded in Syrian Civil War and died while being treated in Turkey were taken into scope of this study. There isn't reliable information about population density and death records in war area. However we thought that there are more people who are wounded and died in the war area. Additionally, due to settlement of hospitals in Syria near war areas, number of Syrian people transported to Turkey has decreased in time.
Table 5 Abbreviated injury scales of cases. AIS
N
%
3 4 5 6 Total
6 39 58 37 140
4.3 27.9 41.4 26.4 100.0
Table 6 Injury severity sores according to injury regions.
ISS
Body region
N
Mean
Std. deviation
P*
Head and neck Multiple sites Chest and abdomen Extremities
42 76 17 5
37.5 46.3 34.0 27.2
24.2 20.8 23.8 17.4
0.001 0.30 0.25
*p ¼ 0.05 (Mann Whitney U).
In conclusion, it is observed that several childhood deaths occurred in the Civil War of Syria. Their abbreviated injury scale and injury severity score values reported very high. AIS and ISS values and injury patterns show us victims are mostly died of head and neck injuries predominantly caused by bombing attacks. Autopsies revealed fatal intracranial hemorrhages and parenchymal injuries. Contribution Adnan Çelikel, Assistant Professor; contribution: data collect writing and correspondence. Kenan Karbeyaz, Associated Professor; writing and review. Bekir Karaarslan, Assistant Professor; contribution: writing and review. Muhammet Mustafa Arslan, Associated Professor; contribution: idea, writing and review. Cem Zeren, Associated Professor; contribution: data and istatistical analysis. Conflict of interest We have no conflicts of interest to declare. Funding We have no financial disclosures for this article. Ethical approval None. References 1. Levy B, Sidel V. War and public health. New York: Oxford University Press; 1997. 2. Syrian Observatory for Human Rights. Syrian observatory for human rights official website. http://syriahr.com/en/index.php?option¼com news&nid¼1473& Itemid¼2&task¼displaynews#.Uu5MofldWfU [retrieved 30.03.15]. 3. Çelikel A, Karaarslan B, Demirkıran DS, Zeren C, Arslan MM. A series of civilian fatalities during the war in Syria. Ulus Travma Acil Cerrahi Derg 2014;20(5): 338e42. 4. Convention on the rights of the child. United Nations; 1989. http://www.ohchr. org/en/professionalinterest/pages/crc.aspx [retrieved 30.03.15]. 5. http://www.unicef.org/sowc96/1cinwar.htm [accessed 31.10.14]. 6. O'Keefe G, Jurkovich GJ. Measurement of injury severity and co-morbidity. In: Control Injury, Rivara FP, Cummings P, Koepsell TD, Grossman DC, Maier RV, editors. Cambridge University Press; 2001. 7. Levy BS, Sidel VW. War and public health. 2nd ed. New York: Oxford University Press; 2008. 8. Global burden of armed violence. Geneva: Geneva Declaration Secretariat; 2008. 9. Patton GC, Coffey C, Sawyer SM, Viner RM, Haller DM, Bose K, et al. Global patterns of mortality in young people: systematicanalysis of population health data. Lancet 2009;12;374(9693):881e92. 10. http://www.who.int/healthinfo/global_burden_disease/GBD_report_ 2004update_full.pdf [accessed 01.09.14]. 11. Levy BS, Sidel VW. Adverse health consequences of the Iraq War. Lancet 2013;16;381(9870):949e58. n G, Bagnall PM, Sloboda JA, Spagat M. 12. Hicks MH, Dardagan H, Guerrero Serda Violent deaths of Iraqi civilians, 2003-2008: analysis by perpetrator, weapon, time, and location. PLoS Med 2011 Feb 15;8(2):e1000415.
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13. Hicks MH, Dardagan H, Bagnall PM, Spagat M, Sloboda JA. Casualties in civilians and coalition soldiers from suicide bombings in Iraq, 2003-10: a descriptive study. Lancet 2011;378:906e14. 14. Spiegel PB, Salama P. War and mortality in Kosovo, 1998-99: an epidemiological testimony. Lancet 2000; 24;355(9222):2204e9. n G, Bagnall PM, Sloboda JA, Spagat M. 15. Hicks MH, Dardagan H, Guerrero Serda The weapons that kill civilians-deaths of children and noncombatants in Iraq, 2003-2008. N Engl J Med 2009 Apr 16;360(16):1585e8. 16. Alkhuzai AH, Ahmad IJ, Hweel MJ, Ismail TW, Hasan HH, Younis AR. Violence related mortality in Iraq from 2002 to 2006. N Engl J Med 2008 Jan 31;358(5): 484e93. 17. Hebrang A, Henigsberg N, Golem AZ, Vidjak V, Brnic Z, Hrabac P. Care of military and civilian casualties during the war in Croatia. Acta Med Croat 2006;60(4):301e7.
18. Helweg-Larsen K, Abdel-Jabbar Al-Qadi AH, Al-Jabriri J, Bronnum-Hansen H. Systematic medical data collection of intentional injuries during armed conflicts: a pilot study conducted in West Bank, Palestine. Scand J Public Health 2004;32(1):17e23. 19. Brethauer SA, Chao A, Chambers LW, Green DJ, Brown C, Rhee P, et al. Invasion vs insurgency: US navy/marine corps forward surgical care during operation Iraqi Freedom. Arch Surg 2008;143:564e9. 20. Scope A, Farkash U, Lynn M, Abargel A, Eldad A. Mortality epidemiology in lowintensity warfare: Israel Defense Forces' experience. Injury 2001;32(1):1e3. 21. Working Group for Mortality Estimation in Emergencies. Wanted: studies on mortality estimation methods for humanitarian emergencies, suggestions for future research. Emerg Themes Epidemiol 2007;4(9). http://www.ete-online. com/content/4/1/9 [accessed 30.12.14].
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m
Original communication
Childhood casualties during civil war: Syrian experience Adnan Çelikel a, *, Kenan Karbeyaz b, Bekir Kararslan c, M. Mustafa Arslan a, Cem Zeren a a
Mustafa Kemal University, Medical Faculty, Department of Forensic Medicine, Hatay, Turkey Council of Forensic Medicine, Eskisehir, Turkey c Gaziosmanpas¸a University, Medical Faculty, Department of Forensic Medicine, Tokat, Turkey b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 16 February 2015 Received in revised form 16 April 2015 Accepted 30 April 2015 Available online 12 May 2015
In war areas a lot of children die as well as adults. According to UNICEF, almost 2 million children have died in the wars took place in the last 10 years. In this study, we aimed to evaluate demographical data and injury characteristics of Syrian children who were wounded in Syria Civil War and died while being treated in Turkey. Postmortem examination and autopsy reports of 985 forensic deaths from Hatay -a Syrian neighborhood city of Turkey-between January 2012 and August 2014 were analyzed retrospectively. Among 763 Syrian people who were wounded in the war and died while being treated in Turkey, 140 cases (18.3%) who were younger than 18 years of age were taken into the scope of this study. Among those cases 77.9% (n ¼ 109) were male and 22.1% were female. Median ages of female cases are 14 (minemax: 2e18) and median age of female cases are 9 (minemax: 1e18). Frequency distribution is highest between 13 and 18 years of age (n: 71, 50.7%). In 70% (n: 98) of cases, cause of death is bombing and shrapnel injuries, 13.6% (19) of them were killed by gunshot wounds. According to injury sites most of the injuries were reported to be on multiple body parts (54.3%, n: 76) and only head and neck injuries (%30). Cause of death was intracranial bleeding and cerebral parenchymal injury in most of the cases (n: 66, %47.1) followed by vascular damage with external bleeding (n: 15, %10.7) and internal organ damage with internal bleeding (n: 15, %10.7). The cases had very high level Abbreviated Injury Scales and Injury Severity Sores. In conclusion, a lot of children have died in the Civil War of Syria. Their average abbreviated injury scale and injury severity score values reported very high. Children that we evaluated were mostly died of head and neck injuries predominantly caused by bombing attacks and Autopsies of them revealed fatal intracranial hemorrhages and parenchymal injuries. © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Civil war Childhood deaths Forensic medicine
1. Introduction Wars have important effects on human lives. While ratio of civil victims to total deaths in World War I were about 14%, it reached 90% in 1990's.1 Since the beginning of the Syrian Civil War over 130,000 people have died, Nearly 4 million people have fled the country and become refugees of which 1,738,448 came to Turkey.2 In war areas children are seriously affected too.3 A child is any human being below the age of eighteen years, unless under the law
* Corresponding author. Tel.: þ90 326 229 10 00; fax: þ90 326 245 56 54. E-mail addresses: [email protected] (A. Çelikel), drkenankarbeyaz@ hotmail.com (K. Karbeyaz), [email protected] (B. Kararslan), [email protected] (M.M. Arslan), [email protected] (C. Zeren).
applicable to the child, majority is attained earlier.4 According to UNICEF It is estimated that; about 2 million child have died, 4e5 million have been wounded and 12 million lost their homes in the wars that took place in the last 10 years.5 Hatay is a Syrian neighborhood province of Turkey. City Center Antakya where main hospitals are located is 60 km's away from the Syrian border. Many wounded people from Syria have been being treated here for nearly four years because of the civil war in Syria. The wounded refugees evacuated from the war zone for treatment who subsequently died here are considered as legal cases since they died in Turkey. In this study, we aimed to evaluate demographical data and injury characteristics of Syrian children who were wounded in Syria Civil War and died while being treated in Turkey.
http://dx.doi.org/10.1016/j.jflm.2015.04.021 1752-928X/© 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
2
A. Çelikel et al. / Journal of Forensic and Legal Medicine 34 (2015) 1e4
2. Material and method
Table 2 Causes of injury.
In our country postmortem examination and autopsy is performed for all legal deaths including caused by war related deaths. The data were collected retrospectively from total number of 985 autopsy records held by Ministry of Justice at Antakya Court House, between January 2012 and August 2014. Autopsies done to Syrian people who were wounded in the war and died while being treated in Turkey were 763 in total. Among them 140 (18.3%) who were younger than 18 years of age were taken into the scope of this study. Information related to incidents is obtained from hospital records which were taken from the families and relatives of the victims. Each case were evaluated according to their age, sex, injury method, injury regions, Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) which was calculated according to the severity of injury of body parts head, neck, face, chest, abdomen and extremity.6 The scores were rated by two forensic medicine specialists together (A.Ç&C.Z). Cases that died of natural death were excluded from the study. Obtained data are analyzed by SPSS (Statistical Package for Social Sciences) for Windows 13.0 Software and Mann Witney U test is performed. 3. Results Of all cases 77.9% (n: 109) is male and 22.1% is female. Median ages of male cases are 14 (minemax: 2e18) and median age of female cases are 9 (minemax: 1e18) (Table 1). Frequency distribution is highest between 13 and 18 years of age (n: 71). In 70% (n: 98) of cases cause of death is bombing and shrapnel injuries, 13.6% (n: 19) of them were killed by firearm bullets. Deaths because of blunt force injuries caused by hitting to hard surfaces, collapse of buildings and foreign objects due to explosions constitute 19 cases. Four children died in car crash that occurred near battlefield or while escaping from there. Injury features examined during autopsy were related to: firearms, bombing and shrapnel injuries, burns, moving objects due to explosions, blunt force injuries due to imploding of buildings (Table 2). According to injury sites most of the injuries (54.3%, n: 76) were reported to be on multiple body parts. It was followed by only head injuries by 30% (Table 3). For most of the cases cause of death was intracranial hemorrhage (subarachnoid, subdural, epidural) with cerebral parenchymal injury which was followed by external bleeding and internal organ damage with internal bleeding (Table 4). Abbreviated injury scales of all cases are documented to be 3 and more than 41.4% (n: 58) of all is 5 (Table 5). Mean of injury severity sores is 41.52 ± 22.62 and according to injury regions the only significant difference of ISS score was found in multiple body region injuries when compared with other regions (Table 6). When comparing the cases according to gender and age there was no significant differences with type of trauma sustained, injured body regions by using Mann Witney U test (P > 0.05).
Cause
Number (%)
Gunshot wounds Bombing and shrapnel Blunt force injury Car crash Total
19 98 19 4 140
(13.60) (70.0) (13.60) (2.90) (100)
4. Discussion Armed violence in wars is a worldwide public health problem against humanity.7,8 Mostly young adults are killed in wars, as well as children and old people may be victims. It is reported that for the individuals between 10 and 24 years of age, 2.8% is dying because of wars.9 East Mediterranean countries are the places where the war caused deaths mostly take place.10 Reflections of the ongoing civil war strongly affects Turkey because of the neighborhood relations. The wounded people from Syria are being treated in Turkey especially in Hatay as a neighborhood city and some of them die here during their treatment. An important ratio of Syrian people died in our province was children (18.3%). Studies on casualties of Iraq War which started in 2003 showed civil casualties were far higher than military deaths. Most of the civilians were killed by bombing from air attacks and suicide bombers.11e13 In this study injuries were distributed mostly as multiple part and head injuries, death was mostly caused by bombing with shrapnel injuries. Those data show civilians are hit by bombardments (both from air and land) without any distinction from military targets. A study from Kosovo war reported: men died in the war were far more than women between 1998 and 1999. Same study showed the ratio of men and women killed in the war between 0 and 14 years of age were similar.14 It is thought that children deaths are increasing because they are unable to perceive the danger; they lack of knowledge about protection methods and can't escape. Additionally shrapnel injuries, house collapses and other car crashes occurred during escape caused by bombing of civilian settlements. According to the studies on Iraq War 14% of the people who are killed were children.15 By the start of war there was an increase in death of children in younger than 15 year of age.16 Another study showed, among the 22,066 Iraqi civilian victims demographically identifiable as men, women, or children, 9.7% were children (n ¼ 2146) and among 2146 child deaths 26.0% were identified as boys, 13.9% as girls, and others sex was unreported.12 It is reported that, 23% of all victims were civilians in Croatia war. Among this civilian 15.8% of them were children and 27.9% was woman.17 A study from Palestine reported 9% of injured people in the war was women and 12% was children younger than 14 years of age.18 Majority of the child victims were between 13 and 18 years of age (Table 1) In our study most of the child victims were male and -according to information obtained from families or relatives of the victims-none of them were fighters.
Table 1 Demographical data of cases.
Sex Male Female All cases
N (%)
Minimum
Maximum
Median
109 (%77.9) 31 (%22.1) 140
2 1 1
18 18 18
14 9 12
ISS
140
9
75
41.5 ± 22.6
Treatment period (day)
140
0
60
5.08 ± 8.7
Table 3 Distribution of injured body parts. Body part
Number (%)
Head & neck Chest & abdomen & back Extremities Multiple parts Total
42 17 5 76 140
(30) (12.10) (3.60) (54.30) (100)
A. Çelikel et al. / Journal of Forensic and Legal Medicine 34 (2015) 1e4
3
Table 4 Causes of death. Cause of death
Number
Intracranial hemorrhagea & cerebral parenchymal injury External bleeding Organ damage & internal bleeding Organ damage & complications Intracranial hemorrhage & internal bleeding Spinal fractures &respiratory paralysis Burns & complications Cerebral parenchymal & organ damages & internal, external bleeding Total a
Total (%)
Male
Female
50 11 14 10 12 1 7 4 109
16 4 1 3 6 e 1 e 31
66 (47.1) 15 (10.7) 15 (10,7) 13 (9.3) 18 (12.9) 1 (0.71) 8 (5.71) 4 (2.9) 140 (100)
Epidural, subdural, subarachnoid hemorrhage.
A study comparing casualties in early and late periods of Iraq War reported that, in late period of the war more casualties with fragment wounds, fewer gunshot wounds were reported.19 In our study most of the deaths were due to bombing and shrapnel injuries, deaths caused by gunshot wounds were quite a few. AIS and ISS values of casualties were very high (41.52 ± 22.62). We thought such high values are results of intensive use of bombings. To best of our knowledge, there isn't any study in the literature on childhood casualties in terms of injury types and properties. In a few studies in which injury sites are evaluated, it is reported that: injury ratios are similar according to body parts, head, neck, chest and abdominal injuries are more lethal than extremity injuries. One documented that most of the victims were lost in prehospital phase and in the first 30 min.20 Another study documented the most common injuries were involving the muscles and bones, followed by abdominal region, neural system, thoracic organs, and cardiovascular system.18 Past studies have not evaluated the injury pattern of children specifically. This the first study evaluating childhood injury patterns in war. In our study, mostly documented injury pattern were multiple body parts injury, followed by head injuries by. Due to direct and indirect effects of the war area there are several difficulties for determining the casualties.21 Syrian children who were wounded in Syrian Civil War and died while being treated in Turkey were taken into scope of this study. There isn't reliable information about population density and death records in war area. However we thought that there are more people who are wounded and died in the war area. Additionally, due to settlement of hospitals in Syria near war areas, number of Syrian people transported to Turkey has decreased in time.
Table 5 Abbreviated injury scales of cases. AIS
N
%
3 4 5 6 Total
6 39 58 37 140
4.3 27.9 41.4 26.4 100.0
Table 6 Injury severity sores according to injury regions.
ISS
Body region
N
Mean
Std. deviation
P*
Head and neck Multiple sites Chest and abdomen Extremities
42 76 17 5
37.5 46.3 34.0 27.2
24.2 20.8 23.8 17.4
0.001 0.30 0.25
*p ¼ 0.05 (Mann Whitney U).
In conclusion, it is observed that several childhood deaths occurred in the Civil War of Syria. Their abbreviated injury scale and injury severity score values reported very high. AIS and ISS values and injury patterns show us victims are mostly died of head and neck injuries predominantly caused by bombing attacks. Autopsies revealed fatal intracranial hemorrhages and parenchymal injuries. Contribution Adnan Çelikel, Assistant Professor; contribution: data collect writing and correspondence. Kenan Karbeyaz, Associated Professor; writing and review. Bekir Karaarslan, Assistant Professor; contribution: writing and review. Muhammet Mustafa Arslan, Associated Professor; contribution: idea, writing and review. Cem Zeren, Associated Professor; contribution: data and istatistical analysis. Conflict of interest We have no conflicts of interest to declare. Funding We have no financial disclosures for this article. Ethical approval None. References 1. Levy B, Sidel V. War and public health. New York: Oxford University Press; 1997. 2. Syrian Observatory for Human Rights. Syrian observatory for human rights official website. http://syriahr.com/en/index.php?option¼com news&nid¼1473& Itemid¼2&task¼displaynews#.Uu5MofldWfU [retrieved 30.03.15]. 3. Çelikel A, Karaarslan B, Demirkıran DS, Zeren C, Arslan MM. A series of civilian fatalities during the war in Syria. Ulus Travma Acil Cerrahi Derg 2014;20(5): 338e42. 4. Convention on the rights of the child. United Nations; 1989. http://www.ohchr. org/en/professionalinterest/pages/crc.aspx [retrieved 30.03.15]. 5. http://www.unicef.org/sowc96/1cinwar.htm [accessed 31.10.14]. 6. O'Keefe G, Jurkovich GJ. Measurement of injury severity and co-morbidity. In: Control Injury, Rivara FP, Cummings P, Koepsell TD, Grossman DC, Maier RV, editors. Cambridge University Press; 2001. 7. Levy BS, Sidel VW. War and public health. 2nd ed. New York: Oxford University Press; 2008. 8. Global burden of armed violence. Geneva: Geneva Declaration Secretariat; 2008. 9. Patton GC, Coffey C, Sawyer SM, Viner RM, Haller DM, Bose K, et al. Global patterns of mortality in young people: systematicanalysis of population health data. Lancet 2009;12;374(9693):881e92. 10. http://www.who.int/healthinfo/global_burden_disease/GBD_report_ 2004update_full.pdf [accessed 01.09.14]. 11. Levy BS, Sidel VW. Adverse health consequences of the Iraq War. Lancet 2013;16;381(9870):949e58. n G, Bagnall PM, Sloboda JA, Spagat M. 12. Hicks MH, Dardagan H, Guerrero Serda Violent deaths of Iraqi civilians, 2003-2008: analysis by perpetrator, weapon, time, and location. PLoS Med 2011 Feb 15;8(2):e1000415.
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