Brain Swelling in Pediatric Cerebral Malaria

Brain Swelling in Pediatric Cerebral Malaria 1.5T MRI to Investigate Potential Etiologies of Brain Swelling in Pediatric Cerebral Malaria Abbreviations: Red Blood Cell (RBC) Parts per billion (ppb) Cerebral malaria (CM) Blood brain barrier (BBB) Abstract Objective: Cerebral malaria (CM) remains a common cause of death in African children. The pathologic hallmark of pediatric CM is sequestration of parasitized red blood cells in the cerebral microvasculature. Recent Malawi-based research utilizing a 0.35T MRI has established that severe brain swelling is associated with fatal CM, but the etiology of brain swelling remains unclear. Autopsy and clinical studies suggest several potential etiologies, but technical limitations of 0.35T MRI precluded optimal investigations into swelling pathophysiology. A 1.5T MRI in Zambia allowed for further investigations including susceptibility weighted imaging (SWI). SWI is an ideal sequence for identifying regions of sequestration and microhemorrhages given the ferromagnetic properties of hemozoin and blood. Methods: Using 1.5T MRI, Zambian children with retinopathy-confirmed CM underwent imaging with SWI, T2, T1 pre- and post-gadolinium, DWI with ADC and T2/FLAIR sequences. Results: Sixteen children including two with moderate/severe edema were imaged. All survived. Gadolinium extravasation was not seen. Cerebral perfusion was intact with DWI abnormalities sparing the gray matter. SWI findings consistent with microhemorrhages and parasite sequestration co-occurred in white matter regions where DWI changes consistent with vascular congestion were seen. Findings consistent with posterior reversible encephalopathy syndrome as a cause of swelling were also present. Interpretations: High field MRI findings indicate that vascular congestion associated with parasite sequestration, local inflammation from microhemorrhages and autoregulatory dysfunction contribute to brain swelling in CM. Keywords: sequestration; venous congestion; hemozoin Introduction: Pediatric cerebral malaria (CM), defined as P. falciparum peripheral parasitemia and unarousable coma with no other coma etiology evident, primarily affects children in sub-Saharan Africa [1]. Although antimalarial agents provide rapid parasite clearance, mortality rates remain high (8-25%) [2, 3]. The pathological hallmark of pediatric CM at autopsy is intravascular sequestration in which parasitized red blood cells (RBCs) adhere to the endothelium of cerebral microvessels. Although malaria causes almost a million deaths per year, neuroimaging capacity is typically limited in malaria-endemic regions. Only one large MRI case series from Malawi using a 0.35T MRI has provided insights into the in vivo structural abnormalities associated with pediatric CM [4]and CM mortality [5]. Other studies and case reports using higher field MRIs have been performed on adults [6, 7], but adult CM appears to represent a different disease syndrome [8]. In adult CM, coma onset largely occurs some days after illness onset in the setting of multisystem organ failure often including hepatic dysfunction, renal failure and gross electrolyte abnormalities. As such, the coma of adult CM is clinically dominated by the effects of a toxic, metabolic encephalopathy. In contrast, in pediatric CM coma onset occurs very early in the malaria illness, often as one of the first signs of the illness, with very limited hepatic or renal involvement and no evident systemic cause for coma. MRI insights gained from imaging pediatric CM to date have been limited to low field MRI technology. The recent pediatric CM MRI study used 0.35T technology to establish that increased intracranial pressure due to increased brain volume is the cause of death in CM [9], but the low field MRI technology was unable to further evaluated the potential etiologies of brain swelling in pediatric CM, so the underlying cause(s) of cerebral edema in CM remains unclear. Further study delineating the underlying cause(s) of swelling is needed to develop appropriate interventions. Potential etiologies suggested by autopsy and clinical studies include any/all of the following: (a) blood brain barrier (BBB) breakdown with resultant vasogenic edema [10, 11]; (b) impaired perfusion resulting in cell death with cytotoxic edema [12]; (c) vascular congestion due to occlusion at the post-capillary venules [13]; (d) hyperemia with auto-regulatory dysfunction due to endothelial injury and CM-associated seizures, anemia and hyperpyrexia [14, 15], [16]; and (e) diffuse cerebral microhemorrhages (i.e. ring hem orrhages) [11]. Hemozoin is an iron-rich breakdown product of the parasites metabolism of hemoglobin [5]. Hemozoin is present primarily in mature, sequestered parasites. Thus, susceptibility weighted imaging (SWI) [17], which is extremely sensitive to the magnetic field inhomogeneity caused by ferromagnetic substances, is an ideal imaging sequence for identifying regions of parasite sequestration. SWI also offers the ability to identify small hemorrhages on the order of several  µg of blood per gram of tissue [18],[19]. We hypothesized that imaging retinopathy-confirmed pediatric CM with a 1.5T MRI including DWI, SWI and gadolinium enhanced sequences would identify pathophysiological mechanisms underlying cerebral edema in pediatric CM and undertook an imaging study of CM in Zambia where 1.5T MRI is available specifically seeking evidence of blood brain barrier breakdown, impaired perfusion, parasite sequestration, autoregulatory dysfunction and microhemorrhages. Material and Methods: Subjects and Recruitment During the malaria seasons (Jan-June) in 2012-2014, comatose children with retinopathy-confirmed [20] CM underwent brain MRI on the 1.5T MRI scanner (Siemens Magnetom Essenza using Syngo MR 200 4A version software, Germany) at the Cancer Diseases Hospital in Lusaka, Zambia within 24 hours of admission. Inclusion criteria were: (1) admission to the pediatric high care unit of the University Teaching Hospital, (2) a Blantyre Coma Score of à ¢Ã¢â‚¬ °Ã‚ ¤ 2 [21], (3) P. falciparum infection as determined by a Paracheck Rapid Diagnostic Test (RDT), (4) the presence of malarial retinopathy, and (5) no other evident etiology for coma. A thick peripheral blood smear to identify parasitemia was also obtained prior to recruitment, but was not immediately available and was not required for inclusion. All children received standard antimalarial treatment, anticonvulsants, antipyretics, antibiotics and blood transfusions, as clinically indicated and in accordance with national treatment guidelin es. As per present treatment standards, no steroids were given. Children with comorbid meningitis as determined by cerebrospinal fluid analysis were excluded from enrollment. Written consent was obtained from the childs parent or guardian. Children with impaired renal function (creatinine à ¢Ã¢â‚¬ °Ã‚ ¥2.0) did not receive gadolinium. This study was approved by the Institutional Review Boards at the University of Zambia, Michigan State University and the University of Rochester. Imaging Gadolinium (Magnevist) doses were determined by individual patient weight and administered intravenously (0.2 mL/kg, 0.1 mmol/kg) by hand injection. The scanning protocol is provided in an appendix. Apparent diffusion coefficient (ADC) calculations were provided by the standard Siemens software algorithms [22]. SWI phase images were collected unfiltered and post-processed with a 6464 high pass filter then viewed using SPIN (signal processing in nMR) software. SWI was also collected with a shorter echo time (15ms) for some subjects to avoid potential aliasing [17]. Interpretation Images were reviewed independently by two radiologists (MJP; neuroradiologist, and SDK; MRI fellowship trained radiologist) and data were managed using NeuroInterp, a web-based program that allows radiographic findings to be entered into a searchable and quantified database [23]. Reader discrepancies, determined in advance of the analysis, were reevaluated by the two radiologists to develop a consensus interpretation. Increased brain volume, the imaging finding associated with fatal cerebral malaria, was rated on a scale from 1-8 with 3 being no edema, 1 and 2 indicating atrophy. An edema score of 4-5 indicated minimal-mild edema, with no loss of sulcal markings. Grade 6 (moderate edema) was defined as loss of some sulcal markings. An edema score of 7 represented moderate/severe edema with diffuse sulcal and cisternal effacement universally evident but without herniation present, and the severe edema score of 8 required sulcal and cisternal effacement with evidence of herniation. MRI findings coded within the NeuroInterp database that could plausibly be associated with the five potential pathogenic mechanisms of brain swelling in CM were then reviewed. Specifically, (a) to evaluate diffuse BBB breakdown causing vasogenic edema, we looked for evidence of gadolinium enhancement [24], (b) to assess for impaired perfusion and subsequent cytotoxic edema we looked for gray matter diffusion weighted imaging (DWI) abnormalities [25], (c) evidence for vascular congestion or venous micro-occlusion was sought by looking for white matter DWI abnormalities [26], (d) autoregulatory dysfunction was evaluated by looking for focal regions of symmetric hemispheric edema of varying confluence in regions susceptible to autoregulatory vulnerabilities [9, 27], and (e) SWI abnormalities were assessed clinically and quantitatively based upon effective voxel susceptibility with the anticipation that these would be located in the same anatomical regions as ring hemorrhages and sequest ration have been identified in prior autopsy studies [28]. Given the small anticipated sample size ( Results: Patient Characteristics and Data Acquisition Twenty three children met study inclusion criteria during the enrollment period. Parents declined participation for 2 children and 5 children were deemed too ill to transfer for imaging or died before imaging could be performed, so 16 subjects were imaged5 (31%) were male and the mean age was 6.4 years (range 1-15). Table 1 provides demographic data and admission clinical characteristics from the 16 subjects who were imaged. Of the 5 consented children who were not imaged, 3 died. Among the 16 subjects imaged, the scans for one patient was non-diagnostic on the SWI sequence due to movement artifact. Renal function could not be ascertained on two children, so these subjects did not receive gadolinium. There were no fatalities among the imaged study subjects and none had clinical sequelae evident at discharge. Table 2 provides the frequencies of the 1.5T MRI findings identified and captured in NeuroInterp. MRI Findings Increased brain volume: None of the subjects had severe (grade 8) edema. Moderate/severe (grade 7) edema was present in 2/16 (13%); moderate (grade 6) edema in 4/16 (25%); minimal/mild (grade 4 5) edema in 7/16 (44%) and no edema in 3/16 (19%). T2 signal changes: The total number of cases exhibiting white matter increased T2 signal was 12/16 (75%), and two distinct patterns were observed: primarily subcortical (10/12, or 83%) and primarily periventricular/peritrigoneal (2/12, 17%) (Figure 1). These generally occurred in isolation; only 2 cases had both findings. Gadolinium enhancement: The expected normal physiological intravascular and circumventricular organ enhancement was evident in all subjects on the post-contrast images (Figure 2). A small region of subtle focal cortical enhancement was seen in one subject with positive SWI signal and no associated T2 abnormalities consistent with a capillary telangiectasia. There was no evidence of gadolinium extravasation in the other 13 patients who received contrast. Cortical findings: Cortical swelling and increased T2 signal was seen in 10/16 (63%), but these signal abnormalities were relatively mild in extent, confluent, and without associated cortical DWI findings. Increased cortical T2 signal was generally diffuse, with only 2/16 (13%) having a posterior predominant pattern [4]. DWI showed restricted water diffusion in the subcortical white matter in 10/16 (63%) which was confirmed by accompanying ADC maps. Basal Ganglia and Thalamus Abnormalities: The structures in the basal ganglia had different levels of involvement. T2/FLAIR signal abnormalities were present in the globus pallidus and putamen in 10/16 (63%), and the caudate in 9/16 (56%). While frequently involved simultaneously, there was generally a region of predominance (Figure 3). Regional differences were also illustrated in the DWI images. Fifty six percent of subjects had DWI abnormalities in the globus pallidus, 13% in the putamen and none in the caudate. Pontine and Brainstem Signal Abnormalities: This was assessed at two levels, within the pons at the level of the middle cerebellar peduncle and within the brainstem at the level of the substantia nigra. Pontine involvement was seen in 9/16 (56%) and brainstem in 11/16 (69%). Abnormalities were usually diffuse, and consisted of generalized increase in T2 signal. However, focal areas of involvement were also seen. Corpus callosum: Showed increased T2 signal and thickening in 10/16 (63%) with 6/10 having associated positive DWI findings as confirmed by ADC maps. The splenium was the primary site of involvement in 9/10 (90%) of cases. SWI Findings: Decreased signal is defined as a positive SWI finding as it localizes to areas of magnetic field inhomogeneity caused by the presence of a ferromagnetic substance (Figure 4). SWI findings were noted along the regions of the venules of both the superficial and deep venous systems corresponding to areas of parasite sequestration and ring hemorrhages. SWI resolution did not allow distinction between gray and white matter involvement in the cerebellum. One SWI dataset was not interpretable due to severe motion artifact. In the remaining cases, 7/15 (47%) showed abnormal paramagnetic signal within the following regions of the parenchyma: corpus callosum (7/15, 47%), sub-cortical white matter (6/15, 40%), cerebellum (5/15, 33%), lenticulae striate (5/15, 33%), and periventricular white matter (2/15, 13%). In two subjects, both the internal capsule and optic radiation had abnormal paramagnetic signal. The susceptibility of heavily infected red blood cells is ~1880 parts per billion (ppb) relative to water [18]. The effective voxel susceptibilities in the corpus callosum and junction of the cortical gray and white matter was 50 ppb relative to water in SWIM. As distributed within the voxel, this represents a 1/38th decrease in susceptibility. Given the voxel size of 0.5 x 0.5 x 2.0 mm3, this represents 1/78th  µL. Assuming the capillary volume is ~5% (or 1/20th of the pixel) [29], this indicates that ~half of the capillaries are filled with hemozoin. The combination of moderate to severe symmetrical cortical swelling (edema score of 6 or 7), with corresponding underlying subcortical white matter changes with associated DWI and ADC findings was evident in 4/16 (25%) of cases (Figure 5) with two of the four showing a predominantly posterior distribution. Table 3 summarizes the MRI findings seen using 1.5T in 16 Zambian children with CM in the context of the proposed mechanisms for brain swelling in CM and the 1.5T MRI findings anticipated for each mechanism. Discussion: MRI findings using a 0.35T MRI have shown that death from pediatric CM occurs due to increased brain volume [9] but low field MRI was unable to further delineate the etiology for the brain swelling. Interventions studies aimed at reducing or preventing cerebral edema in CM would ideally target the underlying mechanism of swelling. Existing clinical and autopsy data suggest at least five potential etiologies for brain swelling in CM. In this study, we describe what the MRI findings associated with each of these potential etiologies would be and then used 1.5T MRI in children with retinopathy-confirmed CM to identify the presence or absence of findings consistent with each of the five proposed etiologies. As such, the results of this study can be subdivided into evidence both for and against these specific potential origins of brain swelling in pediatric CM. Decreased SWI signal was evident on the brain MRIs of children with CM and furthermore these changes were seen in regions where autopsy studies have shown microhemorrhages (Figure 6) as well as in the regions where sequestration is common. Since the SWI signal effectively identifies blood and hemozoin, both sequestration and ring hemorrhages were likely identified. Marked T2/DWI abnormalities were evident in the subcortical brain regions most sensitive to venous outflow obstruction. If perfusion is obstructed in regions with SWI signal changes, then blood flow to the tissue would decrease by ~50% which is consistent with what is seen in an animal model of malaria where blood flow was found to be reduced to 53% +/- 12% [29]. In the setting of the sequestration-associated SWI abnormalities and intact large venous drainage systems (i.e. no venous thrombosis), the T2/DWI findings are strongly suggestive of a venous obstruction phenomenon in the capillary bed system. Much of what is known about pediatric cerebral malaria has been learned from autopsy studies, so it is reassuring to see that the distribution of microhemorrhages and parasite sequestration found in prior autopsy studies are very similar in distribution to the microhemorrhages and parasite sequestration identified in living children who survived CM. Vasogenic edema was demonstrated by increased T2 signal in the white matter. Cytotoxic edema has a similar appearance, but is accompanied by restricted water motion identified by increased DWI signal. Both were evident in this cohort, with cytotoxic being more common. This tended to be significant and diffuse. None of these children died and there were no clinical sequelae at discharge, suggesting that the process is reversible, and may represent early cytotoxic edema rather than tissue infarction. MRI findings of symmetrical cortical swelling with underlying white matter changes were seen, consistent with posterior reversible encephalopathy syndrome (PRES) and suggestive of autoregulatory dysfunction. Pediatric CM is congruent with many other clinical conditions associated with PRES. Specifically, pediatric CM generally involves a rapid neurologic deterioration, usually in the setting of seizure, followed by relativity prompt full recovery in most patients. Radiographically, brain swelling with underlying vasogenic edema associated with positive DWI findings is the hallmark of both CM and PRES [4, 16]. Autoregulatory dysfunction as a result of the primarily endothelial process associated with parasite sequestration in CM may result in vasoconstriction coupled with hypoperfusion causing vasogenic edema and associated brain swelling. This is the favored theory for the etiology of the radiographic findings seen in PRES [27]. We found no evidence of cortical cytotoxic edema and there was no radiographic evidence of gadolinium enhancement although gadolinium was clearly seen within the vessels and in circumventricular organs. Gadolinium, as a contrast agent, is chelated by a range of very small molecules (Magnevist 0.54kDa)[30]. These agents are all hydrophobic, so they do not cross the intact BBB. At autopsy in CM, areas of sequestration show fibrinogen (340kDa)[24] leakage and ring hemorrhages which require sufficient BBB breakdown to allow a deformable, non-parasitized blood cells (7  µM) to escape. The SWI imaging in this study identified ring hemorrhages so some BBB breakdown associated with their presence must have occurred, but if there was associated gadolinium extravasation, the quantity and concentration of gadolinium was insufficient to be visually evident on MRI. Gross BBB breakdown indicative of severe vasogenic edema was not evident in this small series of non-fatal pediatric CM. This study is limited by the small sample size, less severe disease spectrum, and lack of a comparison group. In Zambia, children felt to be at risk of imminent death were not imaged since transport for imaging there requires ambulance transportation to an adjacent facility. The small number of subjects prevented meaningful quantitative analyses despite the use of NeuroInterp. Although no a prior analyses were planned, we did conducted a post-hoc comparison to determine if the edema score or the presence of SWI, DWI, or focal cortical abnormalities was associated with age, coma duration prior to admission or the seizures prior to admission. No associations were found (all ps >0.05). The absence of subjects with severe brain swelling or fatal disease may have impacted our findings, as florid BBB breakdown might not occur to a significant degree in less severe CM. Normal MRIs on a similar aged comparison group were not available. In the Zambian setting, most imaging is obtained on adva nced disease with normal images being uncommon. Acquisition of imaging in an age-comparable group of healthy children was not feasible given the risk of sedation, particularly in this environment. Finally, more quantitative MRI analyses would have allowed more optimal assessments, but the power injections equipment required to obtain perfusion studies and/or dynamic contrast enhanced studies, which could detect contrast influx too small to be visually evident, is prohibitively expensive and was not available in this resource limited setting. Conclusions: Pediatric CM brain MRI findings in non-fatal cases using 1.5T technology suggest that vascular congestion, autoregulatory dysfunction, and microhemorrhages likely contribute to brain swelling pathogenesis. References [1] WHO, World Malaria Report, 2011. http://www.who.int/malaria/publications/world-malaria-report-2016/report/en/ [2] A.M. Dondorp, C.I. Fanello, I.C. Hendriksen, E. Gomes, A. Seni, K.D. Chhaganlal, K. Bojang, R. Olaosebikan, N. Anunobi, K. Maitland, E. Kivaya, T. Agbenyega, S.B. Nguah, J. Evans, S. Gesase, C. Kahabuka, G. Mtove, B. Nadjm, J. Deen, J. Mwanga-Amumpaire, M. Nansumba, C. Karema, N. Umulisa, A. Uwimana, O.A. Mokuolu, O.T. Adedoyin, W.B. Johnson, A.K. Tshefu, M.A. Onyamboko, T. Sakulthaew, W.P. Ngum, K. Silamut, K. Stepniewska, C.J. Woodrow, D. Bethell, B. Wills, M. Oneko, T.E. Peto, L. von Seidlein, N.P. Day, N.J. White, Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial, Lancet 376(9753) (2011) 1647-57. [3] M.E. Molyneux, T.E. Taylor, J.J. Wirima, A. Borgstein, Clinical features and prognostic indicators in paediatric cerebral malaria: a study of 131 comatose Malawian children [see comments], Q J Med 71(265) (1989) 441-59. [4] M.J. Potchen, S.D. Kampondeni, K.B. Seydel, G.L. Birbeck, C.A. Hammond, W.G. Bradley, J.K. DeMarco, S.J. Glover, J.O. Ugorji, M.T. Latourette, J.E. Siebert, M.E. Molyneux, T.E. Taylor, Acute brain MRI findings in 120 Malawian children with cerebral malaria: new insights into an ancient disease, AJNR Am J Neuroradiol 33(9) (2012) 1740-6. [5] F. Paul, S. Roath, D. Melville, D.C. Warhurst, J.O. Osisanya, Separation of malaria-infected erythrocytes from whole blood: use of a selective high-gradient magnetic separation technique, Lancet 2(8237) (1981) 70-1. [6] D.D. Rasalkar, B.K. Paunipagar, D. Sanghvi, B.D. Sonawane, P. Loniker, Magnetic resonance imaging in cerebral malaria: a report of four cases, The British journal of radiology 84(1000) (2011) 380-5. [7] S. Vyas, V. Gupta, A. Hondappanavar, V. Sakhuja, N. Bhardwaj, P. Singh, N. Khandelwal, Magnetic resonance imaging of cerebral malaria, The Journal of emergency medicine 42(5) (2012) e117-9. [8] R.J. Maude, F. Barkhof, M.U. Hassan, A. Ghose, A. Hossain, M. Abul Faiz, E. Choudhury, R. Rashid, A. Abu Sayeed, P. Charunwatthana, K. Plewes, H. Kingston, R.R. Maude, K. Silamut, N.P. Day, N.J. White, A.M. Dondorp, Magnetic resonance imaging of the brain in adults with severe falciparum malaria, Malaria journal 13 (2014) 177. [9] K.B. Seydel, S.D. Kampondeni, C. Valim, M.J. Potchen, D.A. Milner, F.W. Muwalo, G.L. Birbeck, W.G. Bradley, L.L. Fox, S.J. Glover, C.A. Hammond, R.S. Heyderman, C.A. Chilingulo, M.E. Molyneux, T.E. Taylor, Brain swelling and death in children with cerebral malaria, N Engl J Med 372(12) (2015) 1126-37. [10] H. Brown, S. Rogerson, T. Taylor, M. Tembo, J. Mwenechanya, M. Molyneux, G. Turner, Blood-brain barrier function in cerebral malaria in Malawian children, Am J Trop Med Hyg 64(3-4) (2001) 207-13. [11] K. Dorovini-Zis, K. Schmidt, H. Huynh, W. Fu, R.O. Whitten, D. Milner, S. Kamiza, M. Molyneux, T.E. Taylor, The neuropathology of fatal cerebral malaria in malawian children, The American journal of pathology 178(5) (2011) 2146-58. [12] N.A. Beare, S.P. Harding, T.E. Taylor, S. Lewallen, M.E. Molyneux, Perfusion abnormalities in children with cerebral malaria and malarial retinopathy, J Infect Dis 199(2) (2009) 263-71. [13] M.J. Ponsford, I.M. Medana, P. Prapansilp, T.T. Hien, S.J. Lee, A.M. Dondorp, M.M. Esiri, N.P. Day, N.J. White, G.D. Turner, Sequestration and microvascular congestion are associated with coma in human cerebral malaria, J Infect Dis 205(4) (2012) 663-71. [14] P. Brodersen, O.B. Paulson, T.G. Bolwig, Z.E. Rogon, O.J. Rafaelsen, N.A. Lassen, Cerebral hyperemia in electrically induced epileptic seizures, Arch Neurol 28(5) (1973) 334-8. [15] I. Prohovnik, S.G. Pavlakis, S. Piomelli, J. Bello, J.P. Mohr, S. Hilal, D.C. De Vivo, Cerebral hyperemia, stroke, and transfusion in sickle cell disease, Neurology 39(3) (1989) 344-8. [16] W.S. Bartynski, Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features, AJNR Am J Neuroradiol 29(6) (2008) 1036-42. [17] E.M. Haacke, Y. Xu, Y.C. Cheng, J.R. Reichenbach, Susceptibility weighted imaging (SWI), Magn Reson Med 52(3) (2004) 612-8. [18] S. Hackett, J. Hamzah, T.M. Davis, T.G. St Pierre, Magnetic susceptibility of iron in malaria-infected red blood cells, Biochim Biophys Acta 1792(2) (2009) 93-9. [19] T. Bosemani, S.I. Verschuuren, A. Poretti, T.A. Huisman, Pitfalls in Susceptibility-Weighted Imaging of the Pediatric Brain, J Neuroimaging (2013). [20] N.A. Beare, T.E. Taylor, S.P. Harding, S. Lewallen, M.E. Molyneux, Malarial retinopathy: a newly established diagnostic sign in severe malaria, Am J Trop Med Hyg 75(5) (2006) 790-7. [21] M.E. Molyneux, T.E. Taylor, J.J. Wirima, A. Borgstein, Clinical features and prognostic indicators in paediatric cerebral malaria: a study of 131 comatose Malawian children, Q J Med 71(265) (1989) 441-59. [22] Siemens, MRI Protocols 2010. http://www.healthcare.siemens.com/magnetic-resonance-imaging/magnetom-world/clinical-corner/protocols. [23] M.J. Potchen, S.D. Kampondeni, K. Ibrahim, J. Bonner, K.B. Sey

The Americanization of Puerto Rico :: American History

The Americanization of Puerto Rico When island inhabitants first heard that Americans were planning on invading Puerto Rico and driving out Spain's rulers, Puerto Ricans welcomed the North Americans to their home. (To view an in-progress work dealing with the Spanish-American War from a pro-colonial expansion point of view, visit this site/ For an objective historical account view this site). The Puerto Ricans were tired of not having a voice in politics and government and with the knowledge that America was a democracy, there was hope that this status quo would change. Although Puerto Ricans felt sentiments of fear at the arrival of the Americans, this did not curb their welcoming and enabling the American invasion. Unfortunately, the outcome of the invasion was not as positive as was thought it would be. During early U.S. rule, Puerto Ricans still were not included in the majority of governmental relations, and as with Spaniards, Americans who were sent to rule in Puerto Rico had never been there before and were i gnorant about the history, culture, Spanish language, etc. Basically, Puerto Rico continued being ruled by foreigners who sought to complete their own interests, as opposed to looking to what are the interests of the nation they are invading and ruling. A cogent metaphor in Ferrà ©'s novel for the unrequited hopes that Puerto Rico had when United States invaded is Tony Torres, who is supposedly going to dance in Kerenski's adaptation of Swan Lake and Firebird . The people who lived in Machuelo Abajo reacted to the news of Tony with respect and excitement. In my view, the initial reactions of Machuelo Abajo's young people, were on a smaller scale, comparable to the reaction of Puerto Ricans, especially the elite, to the proposed American invasion. Here is a sample of the reaction to Tony's being selected as Prince in the ballet school's production: "The young people in Machuelo Abajo saw him as a hero; it was the first time anyone from the slums had ever danced at La Perla or taken part in any way in any of its elegant cultural events. When posters advertising the performance, with Tony's picture, appeared all over town-affixed to the telephone poles and to the walls of buildings and to fences-the people of Manchuelo Abajo took them down, framed them, and hung them in their living rooms. (Ferrà ©, p. 170)" The Puerto Ricans, especially upper class, regarded the United States as the most powerful democracy in the world.

Child Soldiers Essay

From the first day, something about these innocent eyes filled with hatred inspired me to write. These eyes are those of a child soldier. Before starting this project, I did not think much of children fighting in wars, but as the research got deeper and my understanding of their situation more thorough, this project became much more than a simple task I had to accomplish. I felt close to these people as they are usually around my age, and some are even younger than me. I am aware of these precious years that make up our childhood and our teenage years. It is during this time in our lives where we discover whom we truly are and what we wish to do with our lives. Being deprived of these crucial years makes it almost impossible for one to grow and start one’s life. These children began their trip into hell when they were abducted by the militia or in some cases even the army. They are then forced to commit horrendous acts in order to harden them and to gain the militia’s trust. Many are forced to slaughter their parents so that even if they want to escape from the militia, they are too ashamed to return home. The militia hurts these child soldiers to the deepest of their beings, and hurts them physically as well. In Sierra Leone, it was reported that limbs were cut off and order to inflict pain on the child and to scare away any NGO’S or the government. This idea of a child holding a gun taller than himself is what inspired me to write my genres. The genres I chose for this particular topic helped me widen my ideas on child soldiers. My persuasive essay went against what I believed as I was trying to prove why child soldiers were a positive thing and how the children themselves wanted to fight for their country. This is an aspect we should never forget when researching about something, the other side of the story. This was done to understand fully the topic from every perspective possible. Another genre that changed my view on child soldier was the epistolary, which is a series of letters recounting a story. This epistolary focused on the life of child soldiers once they became adults. It showed me two different aspects, how one can go on with his life as a soldier and become immune to the evil around, and how one can decide to cut short this brutality and start anew. Two Voices, Two Worlds Apart I am an American boy. In the morning, my mom’s gentle kisses awake me. I’m wearing my new shirt with the red polka dots on it. I pick up my bag and get ready for yet another day of school. I have a hard time at school understanding the math. My days are long and full of work and sports. Around 5 p.m., I go home and treat myself to a nice snack and start my chores. Once I am done, I complain about the homework and wonder when I am ever going to use this. I just had a fight with my mother for breaking a vase, and I am considering running away from her to live with my father. I wish I were as far away from her as possible. I wish I had more freedom to do what I want. To sleep late at night and eat a few sweets. To not go to school. But I cannot do all of this because, I am a child. I am an American boy. In the morning, my mom’s gentle kisses awake me. I’m wearing my new shirt with the red polka dots on it. I pick up my bag and get ready for yet another day of school. I have a hard time at school understanding the math. My days are long and full of work and sports. Around 5 p.m., I go home and treat myself to a nice snack and start my chores. Once I am done, I complain about the homework and wonder when I am ever going to use this. I just had a fight with my mother for breaking a vase, and I am considering running away from her to live with my father. I wish I were as far away from her as possible. I wish I had more freedom to do what I want. To sleep late at night and eat a few sweets. To not go to school. But I cannot do all of this because, I am a child. I am a Limba boy. In the morning, bullets abruptly wake me up. I’m wearing my shirt stained with the stains of my brother’s blood. I pick up my gun and get ready for yet another day of war. I have a hard time understanding the reason for all this evil in war. My days are long and full of hatred and suffering. Around 7 p.m., I go to the camp to wash everyone’s dishes from the lunch that I didn’t have. Once I am done with my chores I lie down on the straw bed and think about everything I could have learned if I had stayed in school. The head officer just whipped me for spilling water; the only thing keeping me from running away is my poor mother who needs my help. I wish I were as close to her as possible. I wish I had more freedom to do what I want. To sleep at night and eat dinner. To go to school. But I cannot do all of this because, I am a child soldier. I am a Limba boy. In the morning, bullets abruptly wake me up. I’m wearing my shirt stained with the stains of my brother’s blood. I pick up my gun and get ready for yet another day of war. I have a hard time understanding the reason for all this evil in war. My days are long and full of hatred and suffering. Around 7 p.m., I go to the camp to wash everyone’s dishes from the lunch that I didn’t have. Once I am done with my chores I lie down on the straw bed and think about everything I could have learned if I had stayed in school. The head officer just whipped me for spilling water; the only thing keeping me from running away is my poor mother who needs my help. I wish I were as close to her as possible. I wish I had more freedom to do what I want. To sleep at night and eat dinner. To go to school. But I cannot do all of this because, I am a child soldier. The Other Side of the Story It is commonly accepted that a child is meant to be provided with whatever comfort for his or her thriving. A child is meant to be cared for, educated and nourished until his adulthood. This is why it is easy to understand how shocking, revolting and inhumane it may seem that a child carries a gun and goes to war. However, in many parts of the world, this perception becomes completely irrelevant. When daily life offers nothing but fear, insecurity and fighting for survival, where widows are more prevailing than capable men protecting their countries from invasion and humiliation, child soldiers become the sole alternative to the tremendously hard and severe reality. Even in the mind of the child, it becomes an absolute necessity. The child moves through a forced maturity regarding the priority to fight for the survival of his family and the freedom of his country. Under such circumstances one shouldn’t forget that going to school becomes an unrealistic dream, and that money often comes to lack in families. The child soldier also puts into account this reality and fights to cover the expenses of his family who are often desperate for money. The country also sends children to war for economical reasons, as it doesn’t have enough money to recruit only adult soldiers. Child soldiers are cheaper than adults and therefore, the government can increase the size of its army. Those child soldiers believe with all their heart and soul that their cause is beyond their life. These children sense a feeling of accomplishment and pride in fighting for their countries. Western ideas of what should or should not be acceptable do not have their place in the sad reality of the life of millions of people in slums in Asia and Africa. These children voluntarily sign up in the army, as they are proud to serve their country. They are devoted to their nation and are ready to pay for the freedom that it deserves with their own life. Their life revolves around this country that has watched them grow and they feel the need to fight for it. â€Å"As long as there is fighting, I am ready to fight,† added Abdul Rahim, a child soldier. â€Å"If peace comes, I’ll go to school.† (Reliefweb) These children are not always forced by adults to fight in wars. The only thing that forces them is their love for their country and the obligations they feel they have for their beloved nation. As they fight, the killing brings them a sense of pride as they have liberated their country from a threat. â€Å"I am proud because I killed an enemy for my country,† said Hayatullah, 16, another child soldier. â€Å"The Taliban wanted to move us from our homes and they destroyed our schools.† (Reliefweb) Not only does it bring them pride to have liberated their country of a threat, but they also feel the need to avenge what has been done to them. Having pride in liberating one’s country does not apply to children only. Nathan Hale, who was a soldier for the Continental Army during the American Revolutionary War, once said, â€Å"I only regret that I have but one life to lose for my country.† (Wikipedia-Nathan Hale) These children do want to go to school, but they cannot because of school closures during wartime. Even if the schools were open, it would be dangerous to spend time there, as they are a target during war. Furthermore, how could these children concentrate on their work and learn new things at school while they are under a perpetual threat of death, and that bombs are being dropped around them? They cannot sit down while the rest of their family is dying in war, fighting for their country. These children have been raised with the thought that they have to fight for it under any circumstance. Age will not be the sole reason that will stop them. Another major reason as to why these children want to fight for their country is because they are aware that this country will one day be theirs. This is their future that they are allowing to be destroyed. An officer, Zapp Brannigan, said â€Å"we fight this battle not for ourselves, but for our children, and our children’s children, which is why I’m forming a children’s brigade† (Tv Tropes). This may be an adult point of view, but it is the way a child thinks when he is fighting. The adults are not the country’ s future, but the children are. What is also extremely unfair is that it is acceptable for European countries to have soldiers, but when it involves African or Asian countries, it becomes a problem. During World War II, thousands of 15-year-old British boys signed up on their own will into the army. No one stopped them even though they knew that they were too young. The few that were stopped signed up again and changed their age to be accepted into the army. Furthermore, many countries nowadays in Europe still recruit young boys in their army. â€Å"In the UK, in 2001, there were 6,000 soldiers under the age of eighteen serving in the armed forces. In March 2002, under pressure from the European Union, the government stated that these soldiers would no longer be sent into combat positions. However, Article 38 of the UNCRC states that fifteen is the minimum age for recruitment and there is no law, which forbids children under eighteen to fight† (The Open University). During World War II, Hitler would enlist boys as young as 10 years old in his Hitler Youth programs and put them in the war. All armies in the Great War used child soldiers. In the beginning of the war the enthusiasm to join the battle was so great that young boys as well as girls could hardly be stopped to enlist. (Children of the Great War) This gesture alone should be able to prove that children can enlist and fight in wars. Not letting them fight for what they believe would be wrong. Child soldiers have always been around, and have existed in almost every country, but today, the views about children as soldiers has radically changed. It is not considered acceptable to make children fight in wars any longer, because they are too young, have not had the chance at an education, or are just not prepared to see such atrocities. However, this does not apply to every child out there, as many are much more mature than others. The U.S State Department’s most recent annual human rights report states that, â€Å"an estimated quarter of a million children, even as young as age 6, have been conscripted to serve as soldiers in dozens of armed conflicts around the world, some with armed insurgencies, such as the Khmer Rouge, the Shining Path of Peru, and Palestinian groups in Lebanon, and some in regular armies, such as those of Cambodia, Uganda, Angola, and Sudan.† (Third World Traveler). The Human Rights Watch also estimates that around 200,000 to 300,000 children are serving as soldiers all around the globe. (Statistics on Child Soldiers) Currently in Somalia, child soldiers are being recruited by the U.S Army to fight against terrorism. Awil Salah Osman continuously prowls the streets of this devastated country with his fully loaded Kalashnikov. The difference between him and the other soldiers in Somalia is that he is a child financed by the United States. The United States economically supports these child soldiers and equips them heavily. Furthermore, several American officers repeatedly said that they were concerned about the use of child soldiers in Somalia, and that they were pushing Somali officials to be more careful about these young soldiers. However, when asked if they financed any of them, an American official responded by saying, â€Å"I have no good answer for that†. (The New York Times) The United States cannot justify for its acts, and it expects to for other countries to change their policies. Money is not always ready during these times of unease in a country, and for this reason, many parents are forced to send their children off to war in order to pay for expenses. The children go to war to be able to financially support their family in any ways they can (Third World Traveler). Jean Paul, a child soldier said, â€Å"I joined the army to get food for my mother, my brothers and sisters† (CyberSchoolBus). Children cost money to their parents, as they have to pay for the expenses in any way they can in such times of distress. These child soldiers often join the militia or the army to be able to get money and pay for their families. On average, these child soldiers will get up to $50 a month, for every month they fight (BBC News). In many cases, if the child is fighting for the militia, the militia sends a wage directly to the family (Third World Traveler). In other cases, the child directly goes to the militia to fight as they know that by doing this they will be off ered regular meals, clothing, or medical attention (Third World Traveler). Children in war, is an extremely delicate subject as most people are against it. Not many debates are held on this topic, as people are almost unanimous on the idea of whether or not children should fight in wars. However, these people only focus on the negative aspects of the war’s influence on children. These points are undeniable, but they are often exaggerated or based on certain cases, not on every case. These children could go to school, and have an education, but these schools are often closed due to the war, and few are the teachers that would still dare go to work during times like these. Furthermore, these children do love their country and many are aware of the dangers that are involved when fighting in war. Nevertheless, their desire to fight and free their country is overwhelming. This desire to fight for one’s country and to fight for what you believe has always existed. Children have always fought in wars and often even lied about their age to be able to fight. Children should be allowed to fight in wars. One Family, Two Fates I was walking back to the camp when a fellow officer stopped me and told me there was mail for me. I was not used to receiving only letters. Who could possibly be sending me letters when I had no one left who cared for me? My parents had long been dead and my only sibling had escaped to the United States to further his learning. We lived in two different worlds, and this fact made the letter even more intriguing. It was from my brother, the same one who had left his country during a time of war for selfish reasons. This is what it said: Dear Banura, Brother, it has been a long time since we last talked and I was starting to wonder about you and your safety there in this country ravaged by war. How are things going back there? Have you won any major battles lately, and most importantly how are you doing? As for me, I am doing great. My job is steady, and though the years pass I continue to be amazed by this city of wonders. The lights of the buildings resemble stars in the night sky. Every child goes to school and has an education. They all live in huge buildings with many other families. What is surprising is that these families are not related but they work things out. Children live with their parents in homes with running water and electricity everywhere. Yesterday when I was walking down the street, I saw two brothers running side by side and it made me think you and I. I miss you deeply and I spend a lot of time thinking about you. Yet, the only images I can imagine of you is when you are holding a gun. As an adult or as a child, it is the only way I can picture you. This is more the reason to let everything go and come to New York with me. I still wish for you to come and join me in this city of wonder, but I know that my hopes are a whim. You have your duties to accomplish back in Sierra Leone and I respect that. I wish you the best, brother. Best regards, Ishmael Beah I sat there under my tent reading these words over and over again. Was all of this true? Could these wonders even exist? I had no way of knowing. My life was resumed to one word, war. I had been kidnapped as a child along with my brother when we were young. We had spent our childhood fighting the war in Sierra Leone. I don’t even know if I can call it a childhood, as we were forced to grow up extremely fast. We had to leave our fantasies behind and learn how to fight like men. During our teen years we had been released for a few years and were sent to a school that was built to rehabilitate child soldiers. I did not take it seriously, as I did not see it taking me anywhere. My brother, on the other hand, had studied hard and said that one day he would go abroad and further his studies. I used to laugh at him and return to playing tag with my friends out in the field. I regret these days. My life could have been different if I had worked. A bullet was shot in the distance and I was brought back to my reality. This was my reality, the camp and the war. During dinner the next day, I decided to write back to Ishmael. After all, he was my brother and the only family I had left. I hastily took out a pen and a piece of paper and jotted down a few words. The few things I had learned during with UNICEF were finally coming in handy. Ishmael, I received your letter and I am glad you still think about me and worry about me. As you can see, I am still alive and I am doing fine. This country may be at war, but that doesn’t mean everyone gets killed. You, of all people, should know better. You lived it. The war is going on steadily and I don’t see any signs of it stopping any time soon. We won a small battle yesterday in the bush as we killed 15 of their soldiers. Only one of our kids died. It is okay he was just 8, he won’t be very missed. I am happy to know that you are doing fine in this city of lights you described. It seems nice, but you are right, I will not join you there. I have work to do here, and a country to serve. Thank you, Officer Banura I sent the letter without any second thoughts. This is how it was done anyways. Nothing could have second thoughts. If we started doubting our first instincts, we would always be wrong, or in the worst case, killed. I went back to my dinner and ate. The bell rang in the distance, and I turned all emotions off. I picked up the gun that was lying by me and ran to the bush. Shock took me over as I reread these lines. â€Å"Only one of our kids died. It is okay he was just 8, he won’t be very missed.† How could he ever say something like this? He once was this child that fought in the bush like a man, giving everything he had. He knew the fear that was triggered from shooting a man. He also knew of the adrenaline rush of seeing that man drop dead on the floor knowing that later on in the camp he would be proclaimed and thanked. My brother had forgotten about these evils and regarded them as normal. This could not be happening. I could not let him forget the little innocent boy that once was my brother. I decided to write another letter to remind him of who he truly was. Dear Banura, Your words comforted me as I now know you are alive. However, they also hurt me so much. To know you have lost your humanity makes me wish that you died out there in the battle. How could you have forgotten what it was like to be a child soldier yourself? A few years back you were not so different from this little boy that died for his country. I, on the other hand, remember it all too clearly. You may only remember the drugs and the good times we had after using them, but I remember the whole story. I had just turned 13 and you were merely 7 years old when the Revolutionary United Front attacked our village. This was back in 1993. The war had started in 1991. We spent three years fighting against the government in Freetown. You remember those days, don’t you brother? The fighting, the killing, the bloodshed, the useless bloodshed. You probably forgot about the atrocities that happened during those years. You were so young, so innocent, and you were given drugs, constantly. You accepted them instantly as you thought they were treats. I do not blame you, I myself did not know any better. I accepted them as well. There is no need to rummage on the bitter past, but I would still wish to remind you of the day in 1996 when UNICEF delivered us from our perpetual sufferings. They helped us flee from Freetown and they gave us an education. It was basic but it still helped me take my mind off of the atrocities I had seen. I worked hard and had even started to learn how to read and write. You on the other hand, showed no effort. It seemed as if you were content with your old life, and that you even wished you could go back to it. I knew all hope for you was lost when you came to my bunk one night and told me â€Å"the neck of this one is in perfect position for cutting with a machete†. You were talking about the boy you had been playing marbles with you a few hours earlier. After a few months in the UNICEF camp, they helped some of us flee from Freetown. I went with them but you decided to stay behind. You said you preferred dying than abandoning your country in a time of need. I often wish you had come with me, but I will never regret this day. It opened up so many more possibilities than the war ever had. I was sent off to New York where I stayed with my foster mother, Laura Simms. Once I was there, I was signed up in the United Nations International School. I later enrolled in Oberlin College where I graduated with a degree in Political science. Right now, I write and tour the United States to explain the atrocities of being a child soldier, while you continue fighting a deadly war that kill thousands of children every year. Unfortunately, I believe all hope is lost for you, brother. I wish for you to regain your senses and your humanity. May God help you, Ishmael Beah The letter was sealed and I sent it off. It was not a careless act, as I rummaged over it for a few hours. If this could not knock some sense into his careless head, nothing will. I though back on my brother’s words, how could one lose all love and pity? I only wished for one thing. For Banura to see that there was a way to get out of all of these atrocities. The escape was simple. He could come to New York, and work alongside with me. All possibility of this may have been lost, but one can still dream after all. The letters were still coming in, and I did not know why. What could Ishmael want to do with me? He knew I was alive and well, so why would he want to keep talking to me? We were so different, what could we talk about? Then I read the letter. The words stung me like wasps. The sorrow in them cut me like blades. He was right. I had told him that he should have known what fighting was like because he had been a soldier, but I had forgotten what being a child soldier was like. Again he was right, the drugs had made that time of my life just seem like a shape in the haze. I hadn’t even realized I was crying until a tear fell on the letter. To add to my pain, I remembered telling another child to dump that little boy’s body into the hole at the other end of the camp. No tears had been shed for him back then, but this was being fixed. I dried my wet face with my sleeve and went back to my tent. I could not cry in public, but I could not hold back the tears, either. I wept for all the men I had killed and all the children I had deprived of a childhood and a life. As if by instinct, I took out my brother’s first letter from under my pillow and reread it. The answer seemed to stand out from the little piece of paper, â€Å"come and join me in this city of wonder†. With eyes half closed I started packing my bags. I wrote down my wish to join my brother as a letter and sent it off. Ishmael, You have been right all along. I have lost myself during all of this fighting and killing. Please accept my apology and open your home to me. Let me join you and start a new life. Your brother, Banura I waited for the reply for endless days. Finally one day the letter came and a few words were written on it. Banura, Join me now. I have arranged your departure with the United Nations. Go to the Lungi International Airport any day in the next six months and take this plane ticket with you. Ishmael My contract with the army was coming to an end. This piece of paper that had sealed me in this world of violence did not mean anything to me but bitter memories of a childhood and a life wasted. Three months after my brother’s last letter, I left this world of turmoil behind me forever. This was back in 2001, one year before the civil war in Sierra Leone ended. I now live with Ishmael, my brother, and we tour around the world explaining what a child soldier does. I help explaining to people the vicious cycle of war and how one is bound to return to being a soldier, as we are not taught anything else. Child soldiers often lack skills to do anything else but fight. This was the case for me, but thanks to my brother, today I live a different life in this city of wonder. Descent Into Hell 1st entry: It was a day like every other in Sierra Leone, where I live with my older brother and my mother. Nothing seemed to be different as everyone was tending to his or her chores. I was feeding the chicken and gathering the eggs for our supper tonight. One egg each. It was more than enough in these times of turmoil and desperation. In the distance I heard a deafening shout. It was my mother. At first, taken by panic, I stood amongst the poultry, paralyzed. I heard gunshots and that was it. I found myself running through this so familiar path to see, standing in front of my door, three buff soldiers holding a gun. I remember that sight, I always will. The object, a gun, used to be so foreign to me. I now am accustomed to the touch of it, as well as the sensation of having it placed in my bare hands. The soldiers were asking my mother where my father was. Little did they know he was deceased for a few years now. They then asked her if she had any sons and where they were. From behind her, my 17-year-old brother appeared. They asked him aggressively if he was ready to join the militia and to fight for his country. He replied that he wasn’t and that he had to remain with my mother to help her. He was shot dead. A bullet, in the head. Not any remorse from the other soldiers. A cry escaped from my mouth. The eyes from one of the soldiers found me. It was the end. â€Å"YOU!† he shouted. I advanced timidly towards him fearing for my life and for my mother’s. He repeated the same question he had asked my brother. What other choice did I have but to say yes and follow them? They allowed me to pack a pear of pants, a pair of shoes and I was gone. My life as I knew it was over. I was only 13. 2nd entry: We walked until dawn the next day through the bush. Everyone was tired but we continued walking. In the distance we could see a camp. It was relatively small. As we entered through the metal gate one thing hit me. It hit me hard. The putrefying smell of rotting flesh. Prisoners from a previous attack had been staked in the middle of the camp to scare away anyone who dared come in. They made me walk past them into a hut on the other side of the camp. There, they gave me a uniform and told me that I was part of the army. This was all too new for me. I did not know what to do or expect, so I simply obeyed and followed the rules. I would soon find out that this would become a habit. To follow the rules blindly. An officer was speaking and telling me about the food schedule. We must all wake up at 5 a.m. and eat in order to be prepared to fight for the rest of the day. We would return at the camp around 8 every night to eat and rest before the next day. For breakfast we were given one egg and a handful of rice. For our lunch we were given bean soup and for dinner we would be handed two pieces of meat and a bowl of rice. He also told me that we had to do a special ritual before starting the training. They said that if I followed the rules I would gain magical powers that would protect me from the bullets. He also informed me that if I did not follow his orders he would hunt the rest of my family down and kill them one by one. The order was plain enough. I had to follow the rules and I would be protected from the bullets. What I found bizarre is that no one asked for my name that day. Newcomers must have been common here. A soldier came up to the officer and started talking to him. I was to follow this soldier to be trained. The officer shouted after us, â€Å"Take care of Pisco, he looks like a sturdy one†. I asked the soldier why the officer had called me Pisco, and he replied in the most natural tone ever, â€Å"It is your new name†. Abu Bakar Bangura, the young and innocent boy living in the village with his mother and brother was dead. Pisco, the sturdy child soldier had taken his place. 3rd entry: During my four months of training, we had to run in the morning and we studied about small arms at night. During the day, we would plough and harvest the fields and we practiced parade drills. To plough the fields, we had to pull a tractor with a rope so that the officers would not have to waste their money on fuel. The training was hard and I had no idea how to hold a gun, shoot and aim. The first couple times I even injured myself and almost shot a man in his leg from not aiming properly. Two other boys were in training with me. Nisu and Shole. They were twins and were taken away from their father a week ago. They were already better than I was but had trouble aiming. Nisu kept missing the aim and a soldier got tired of him and beat him. The beatings were severe and the pains caused from them were horrendous. I know that from experience. The fear of getting beaten everyday was always present, so I tried my best. I could not fail. Nisu and Shole were not as good as me. They were beaten every day and the beatings made it even harder for them to hold the gun in their hands. One day, Nisu was hit in the head with a rock, and fell dead. His brother could not endure the pain of being alone. He starved himself to death, and when the beatings came again, he died. They were thrown by a soldier into the latrines and left there. I still think of them today. That night, the soldiers beat me too. I was beaten unconscious and had to be sent to the hospital. They put an ice pack on my head and waited until I woke up. No tests were done to see if I had a concussion. When I returned to the camp, they beat me again. I nearly died that night. To this day, I still do not know why they beat me. I cried that night, but not only because of the pain of losing Nisu and Shole, nor from the pain my head was inflicting upon me, I cried because even though my training was not over, I had to start killing the enemy. Tomorrow I had to go into the bush for the first time and fight for my life. I knew that this would be the hardest day of my life and that it would be crucial for the rest of my stay here. 4th entry: Before I was sent out to the bush, an officer pulled me over and told me to follow him. Once again I did as I was told. I walked to the end of the camp, next to the latrines. On the ground, attached by ropes, was a boy. The same one who slept in the bunk over mine. He had just turned 10. He was used in the camp to wash the dishes and do the laundry in the river. They gave me my gun and ordered me to shoot him. I asked why. They told me that if I did not shoot him, they wouldn’t be able to trust me. I still did not understand why I had to shoot this young boy but the soldier’s next words convinced me. â€Å"If you do not shoot him, we will give him the gun and he will have to shoot you†. The boy got on his knees and started crying. He asked to be freed and to go back to his mother. The officer slapped him and ordered me to shoot. I shot. This was the first person I ever killed. He certainly wasn’t the last. I still have dreams about the boy of the village that I killed. The dreams keep me awake at night, crying my eyes out. The sobbing face keeps repeating that I killed him for no reason. I regret this act. I killed an innocent boy simply to prove I was trustworthy of killing even more men and women. After that shot was sent, I fell to my knees sobbing. A soldier grabbed me from my hair and threw me on the floor. He told me he would give me a potion that will make me invincible. He gave me a damp cloth and pressed it against my mouth and my nose. I started to feel a bit dizzy yet I was hyperactive. The soldier had drugged me and made me high so that I would be fearless and better in the bush. Nothing felt better than this feeling. The gun felt light in my hands, and the damp bush was almost invisible to me. I felt free and good. This day flew by for me. When I got home that night, my eyes were red and itching and I felt slightly dizzy. The drug was slowly dissipating and the hunger took over. During dinner, we were given two pieces of meat with a little rice. While I was eating my bowl of rice, an excruciating pain was felt in my leg. I had not noticed that a bullet had grazed my thigh and left a deep gash that was bleeding. I was taken to the infirmary and my thigh was bandaged. It did not help with the pain but at least I would not have to sleep on it with all the dirt. Wounds were deadly here as the risk of infection was high and the medicine was scarce. 5th entry: The drugs were the only things that made me want to go back into the bush. This was the only thing I was certain about in this world full of uncertainties. The soldiers would give us cocaine or marijuana. They would often mix cocaine with gunpowder and they would call it brown brown. We would then follow our officers into the bush and they would utter a few words and let us go. â€Å"This is the enemy† and they would give us a direction. No questions were asked. If we asked any questions, we would have a clear answer. Death. Our own team would shoot us. That day I killed my first man on the battlefield. I had climbed at the top of a tree and hid in the dense foliage. There I lay, not moving for what seemed like hours. The humidity and the high temperatures made the thirst unbearable. A man from the opposing army was walking nearby shooting at one of the soldiers in camp with me. From under the foliage I shot. The bullet hit the soldier in the back and he fell on his knees. Blood was gushing from the wound. The soldier’s life I had just saved came up to the dead body and turned him over. He drew a machete from his belt and cut the head off. The soldier dragged the head from the hair and brought it back to camp that night. It was put in the fire. The same fire the food was cooked on. That night, I fell asleep without even taking my dinner. I was alone in the hut enjoying the stillness of the night when an officer burst into the room. He asked, â€Å"Who is here?!† to which I replied by saying Pisco. His face lit up when he heard my name and he started unbuttoning his shirt. He was approaching me and saying things like: do not be scared Pisco, it won’t hurt very much. On a less gentle tone, he told me that if I ever told anyone about anything that will happen tonight, he would execute me and accuse me of treason against my team during the battle. He said he was in charge here and anything he accused me of, would be taken as true. The officer sat next to me and told me to get closer to him. Once again, I obeyed. The officer gagged me and tied me with a rope to the metal bars of the bed. I was laying on my stomach with my face crushed against the hard mattress. Without being able to move, I could feel the officer removing my pants. Once the officer had pleasured himself using my body, he left. He let me behind, mind and body shattered. I wish to never recall that night. This is the last time I will ever write about it. 6th entry: How could I live knowing that this would become a routine? Killing people. I had always thought that no man should have any sort power over another man’s life. Who did we think we were to end someone’s life? Yet, here I was, killing people. I could not live with this in my heart anymore. I had to tell someone, but whom did I have left except for my mother? Even though I wished I could talk to her, I had no way of doing so. I asked some of the older soldiers how they communicated with their family and they told me they would send letters with other soldiers when they went on raids for new recruits in villages. That night, I sat down and wrote my sorrows and my pains to my mother. I told her I would be fine, and that she should not worry about me. I tried reassuring her; by telling her I would come back to her. Then the thought hit me. What if I never returned home? I wasn’t as scared of dying as I was of staying here forever and having to live like this. I did not know how long I was going to stay here. I had to escape. My plan was set in my mind. If I was hurt enough, I would be sent to the nearby hospital and my wounds be tended for. Once I was in shape again, I would run away and join my mother at her village. The only thing that prevented me from doing so was the fear. The fear of being caught and being tortured as a punishment. I was aware of what happened to those that tried escaping. These men are raped, beat to death, buried alive and shot in front of their families. If they are not killed right away they are tortured, forced to reenter the army or arrested and imprisoned. This decision could not be taken over night; I had to think of all the other possibilities. During that time, I would continue to fight to live and to not lose all humanity. A Second Chance Lahlou, Ralia. â€Å"Child Soldiers.† Child Soldiers. Wix, 29 Feb. 2012. Web. 29 Feb. 2012. . Bibliography â€Å"Facts About Child Soldiers | Human Rights Watch.† Human Rights Watch. Human Rights Watch, 3 Dec. 2008. Web. 1 Feb. 2012. . â€Å"Studies Explore Effects of War On Former Child Soldiers.† ScienceDaily. ScienceDaily, 15 July 2010. Web. 1 Feb. 2012. . â€Å"INTERVIEW-Chad Child Soldier, Aged 12, Tells of Horror.† Reuters. Reuters. Web. 7 Feb. 2012. . Johnson, Caitlin A. â€Å"A Former Child Soldier Tells His Story.† CBSNews. CBS Interactive, 11 Feb. 2009. Web. 2 Feb. 2012. . â€Å"Some Facts.† Some Facts [Child Soldiers International]. Child Soldiers Internation, 2007. Web. 18 Feb. 2012. . â€Å"FACTSHEET: CHILD SOLDIERS.† UNICEF. UNICEF. 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Web. 27 Feb. 2012. . â€Å"Karen Human Rights Group | Reports | Interview with an SPDC Child Soldier.† Karen Human Rights Group. 26 Apr. 2006. Web. 1 Feb. 2012. . Wild, Ko. â€Å"Mizzima News.† Interviews on Child Soldiers. 7 Feb. 2011. Web. 29 Dec. 2012. . Steel, Michelle. â€Å"Child Soldiers.† Child Soldiers. Vision, 2008. Web. 29 Feb. 2012. . â€Å"UNICEF in Emergencies.† UNICEF. 29 Apr. 2008. Web. 18 Feb. 2012. . â€Å"Uganda, Child Soldiers Trapped in Vicious Cycle of War.† UNICEF. 17 Feb. 2005. Web. 17 Feb. 2012. . â€Å"Voices Of Young Soldiers.† Voices of Young Soldiers [Child Soldiers International]. Child Soldiers International, 2007. Web. 25 Feb. 2012. .  © BBC World Service, Bush House, Strand, London WC2B 4PH, UK Privacy Statement. â€Å"Children of Conflict.† BBC News. BBC. Web. 29 Feb. 2012. . â€Å"Cover, Concealment, and Camouflage.† Field Manual 21-75 – Combat Skills of the Soldier. US Army. Web. 23 Feb. 2012. . Eaton, Courtney C. â€Å"Child Soldiers.† Teen Ink. Web. 8 Feb. 2012. . Hedemann, Philipp. â€Å"His Head Swimming In Hash, A Former Child Soldier In Burundi Recalls His Many Kills.† Worldcrunch. 29 Feb. 2012. Web. 29 Feb. 2012. . Singer, P. W. â€Å"Experiences of Child Soldiers.† Rowan. 2005. Web. 6 Feb. 2012. . Wakabi, Wairagala. â€Å"Lubanga Trial at the International Criminal Court (ICC).† Lubanga Trial, Week 6: Child Soldiers Tell of First Kill  « Thomas. 6 Mar. 2009. Web. 6 Jan. 2012. . â€Å"Child Soldiers of The Liberation Tiger of Tamil Eelam (LTTE).† Srilanka Terrorist Group. Web. 29 Jan. 2012. . Wessells, Mike. â€Å"Sierra Leone: Child Soldiers.† Pangaea Publishing and Design for Nature & Peoples of the Earth. Nov.-Dec. 1997. Web. 29 Jan. 2012. . Kari, Anna. â€Å"Anna KÃÆ' ¥ri : Ugandan Child Soldiers Freed from the Lords Resistance Army (LRA).† Anna KÃÆ' ¥ri : Ugandan Child Soldiers Freed from the Lords Resistance Army (LRA). Web. 18 Feb. 2012. . Clifford, Cassandra. â€Å"Uganda Child Soldier Awareness Weekà ¢Ã‚ ¦Agreement Signed With LRA.† Uganda Child Soldier Awareness Weekà ¢Ã‚ ¦Agreement Signed With LRA. Foreign Policy Association, 20 Feb. 2008. Web. 18 Feb. 2012. . â€Å"Child Soldiers Global Report 2008 | Produced by the Coalition to Stop the Use of Child Soldiers.† Child Soldiers Global Report 2008. 2008. Web. 20 Feb. 2012. . â€Å"Facts and Figures on Child Soldiers.† Kindernothilfe. 2012. Web. 20 Feb. 2012. . The Road from Soldier Back to Child.† UN News Center. UN. Web. 29 Jan. 2012. . Eisele, Sarah. â€Å"An Exploration of Child Soldiering in Three Countries.† IASSW. Web. 18 Dec. 2011. . â€Å"Child Soldiers | Education | United Nations Educational, Scientific and Cultural Organization.† Education – Child Soldiers. UNESCO. Web. 29 Feb. 2012. . â€Å"Children and Families in Gulu, Uganda Today.† Child Soldiers in Uganda. SOS CHILDREN’S VLLAGES. 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The War During The Cold War Essay - 1408 Words

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