Iraq Health Update -- Conflict fuels Iraqi health crisis

Kingston Reif

05 September 2006
This Update, by Kingston Reif, contains new information about the state of health and health care in Iraq. It is the latest in a series of reports in which Medact has monitored the impact of the war and has reported on its continuing effects.
This is a collection of narratives on various forms of healthcare crises that the Iraqi People face everyday, these days. "Another loud cry in a more and more deaf world!"

“When we went there last week we would not leave the base, indeed walking from building to building in the base we had to put on full body-armour. The security situation has deteriorated, there is no doubt about that”.1 ---Paul Keetch, Liberal Democrat member of the Foreign Affairs Committee
Much has happened since Medact’s Iraq Health Update was published in July 2005. A nationwide constitutional referendum in October was followed by national elections in December to determine the makeup of Iraq’s new government. Yet despite these encouraging developments, a U.S. military report released on 23 January 2006, showed a 30% increase in insurgent attacks in 2005 compared to the previous year.2 The rise in violence has been accompanied by a dramatic increase in the number of kidnappings. According to the Iraq Index Project of the Brookings Institution, up to 30 Iraqis were kidnapped nationwide every day in December 2005.3 The total number of international troops in Iraq is currently 157,000.4
In a remarkably candid assessment that challenges optimistic accounts by the UK and US governments, USAID describes Iraq as a place of ‘social breakdown’ where ‘criminal elements within Iraqi society have had almost free reign.’5 Attached as an appendix to a paper calling on contractors to bid on its $1.3 billion Focused Stabilization in Strategic Cities Initiative (January 2006), the USAID document claims that ‘Baghdad is…divided into zones controlled by organized criminal groups/clans.'6
The disastrous security situation has paralysed the Iraqi health sector. Already devastated by eight years of war with Iran from 1980-1988, the first Gulf War in 1991, and more than twelve years of UN sanctions from 1991-2003, the health situation was tenuous even before the U.S.-led invasion in March 2003. Medact’s previous updates revealed few improvements and many problems in the first two years of the occupation. An analysis of key health indicators reveals that the health sector remains in dire straights as the ‘post-war’ period in Iraq nears the end of its third year.
Iraqi death toll still rising
Dr. Bradley A. Woodruff, a medical epidemiologist at the U.S. Centers for Disease Control and Prevention, referring to the study published in The Lancet in late October 2004 that put the number of Iraqi civilian dead as a result of the U.S. invasion at 98,00, called it “ the most valid estimate.”7
In Medact’s last update it was reported that the British government had endorsed figures published by the Iraqi Ministry of Health that put the number of civilian dead between 5 April and 5 October 2004 at 3,853 and the number of wounded at 15,517. These figures may or may not have included insurgent dead and wounded. As was noted at the time, this count only covered a 6-month period and included only casualties attributed to insurgent action.8 Iraq’s Interior Ministry has now taken over responsibility for counting Iraqi dead and their most up-todate figures are that 8,175 Iraqis – including civilians, soldiers, and police – were killed by insurgents from August 2004 to May 2005.9
Until recently, the U.S. has said very little about Iraqi civilian casualties. However in late October 2005, it was reported in the New York Times that the U.S. military has in fact been monitoring civilian deaths in Iraq.10 Then, in an answer following a highly publicized speech on December 12, 2005, the President put the number at ‘30,000, more or less.’11 This is almost exactly the same as figures kept by Iraq Body Count (www.iraqbodycount.net).
The problem with estimates provided by Iraqi officials and Iraq Body Count is that they only include those deaths that have resulted directly from violence. A much more comprehensive nationwide survey of all cause mortality in Iraq was published in The Lancet in late October 2004. Researchers, led by Dr. Les Roberts, interviewed 988 households and, after extrapolating the results to the rest of the country, found that post-invasion excess mortality amounted to 98,000 civilian deaths. Violence – rather than myocardial infarctions, cerebrovascular accidents and chronic diseases that had been the leading causes of death prior to the invasion – accounted for most of these deaths. Any attempt to gauge mortality in the midst of a conflict will be marked by a degree of uncertainty, but what should be beyond dispute is that the Lancet study is based on sound methodology. Yet in 2005 this continued to be questioned in the press.12 It is interesting that Roberts used nearly identical sampling techniques to study mortality in the Democratic Republic of the Congo (DRC) in 2000, and that U.S. and British officials have quoted these findings without question in speeches condemning the killing in this case.13
Meanwhile, innocent Iraqis are continuing to be killed and wounded at an alarming rate. According to one recent estimate, nearly 800 were killed in January 2006, making it the deadliest month since September 2005.14 In addition to Iraqi casualties, 2274 Americans have been killed and 16,420 have been wounded. More than100 UK soldiers have been killed.15
Deepening health crisis
“The only thing I eat all day is a piece of bread with some tomatoes and fried potatoes… .If we eat more than this our father doesn’t let us eat the next day.”16
--- Khalid Amir, a ten-year-old boy living in Baghdad

In 2004 Medact’s last Iraq update provided detailed excerpts from the Iraq Living Conditions Survey. COSIT, UNICEF, and the WHO, are currently involved in survey efforts that have either not yet begun or whose results are not yet available to the public.17 While statistics in a violence-plagued environment such as Iraq are hard to come by, some recent health data has been reported: · According to Hayder Hussainy, a senior official at the Ministry of Health, approximately 50% of Iraqi children suffer from some form of malnourishment and one child in10 is also suffering from chronic disease or illness.18
· A UN study undertaken in 2005 found that a third of the children in southern and central Iraq are malnourished (the same as in 2003).19
· According to a 2004 Health Ministry study, ‘easily treatable conditions such as diarrhoea and respiratory illness account for 70% of deaths among children.’20
Mental health a serious concern
“The only things they [Iraqi children] have on their minds are guns, bullets, death and a fear of the US occupation.”21
Maruan Abdullah, spokesman for the Association of Psychologists of Iraq (API)

The security situation has taken a terrible toll on the mental health of the Iraqi population particularly children. According to a report by The Association of Psychologists of Iraq (API) on 5 February 2006, ‘children in Iraq are seriously suffering psychologically with all the insecurity, especially with the fear of kidnapping and explosions.’22 The API surveyed over 1,000 children across Iraq during a four-month period and ‘92% of the children examined were found to have learning impediments, largely attributable to the current climate of fear and insecurity.’23 This summer, the Iraqi Red Crescent Society (IRCS) intended to develop services to aid traumatized children but due to a shortage of funding the project was postponed.24
Iraqis are not the only ones suffering from trauma and mental disorders. Many U.S. soldiers returning home from Afghanistan and Iraq are showing a higher incidence of post traumatic stress disorder (PTSD) than in previous American wars. Figures released by the US Department of Veterans Affairs (VA) show that ‘up to a third of US troops returning from Iraq or Afghanistan – about 40,000 – suffer mental health problems.’25
According to a report in The Independent on 16 February, 2006, at least 1,333 UK servicemen and women – almost 1.5% of those who served in the Iraq war – have returned with serious psychiatric problems.
Lack of health personnel and supplies
“It's the worst health care system Iraq has ever known.”26
Dr. Waleed George, chief surgeon at Al Sadoon Hospital in Baghdad, referring to the deteriorating health situation throughout Iraq due to the exodus of qualified health personnel

The Iraqi Health Ministry estimates that 25% of Iraq’s 18,000 physicians have left the country since the invasion in 2003.27 Sources we contacted who have recently lived or traveled in Iraq report that doctors and other health workers are being attacked, shot at, threatened, kidnapped, and told to leave the country or die.28 It appears doctors are targeted because they are perceived to be able to pay ransoms to kidnappers. One estimate puts the number of doctors kidnapped since the invasion at 25029, while an Iraqi Doctors Association puts the number killed in 2005 at 65 – more than in either 2003 or 2004.30 The exodus of medical personnel has had a devastating affect on the Iraqi health sector. Hospitals are understaffed and inexperienced medical residents undertake operations and procedures they are not qualified to perform. ‘It’s creating a brain drain,’ notes Amer Hassan Fayed, assistant Dean of political science at Baghdad University. ‘We could end up with a society without knowledge. How can such a society make progress?’31
The Iraqi health sector also lacks basic medical supplies. The largest emergency hospital in Baghdad, Al-Yarmouk, lacks medicine, disinfectants, surgical requirements, bed sheets, cleaning aids, and personnel.32 A medical aid worker we contacted in Basra – who requested anonymity for security reasons – informed us that most hospitals in the British controlled city have limited – and in some cases no – supplies of IV fluids, IV cannulae, antibiotics and oxygen.33 Many Iraqis are forced to purchase these on the black market, where prices are often exceedingly high.34
Water, sanitation and electricity crisis
"Imagine yourself trying to operate on a patient in a two-hour surgery and the power goes out… .You pray to God, and you sweat."35
Dr. Waleed George

According to a recent audit by the Special Inspector General for Iraq Reconstruction (SIGIR), ‘the US government will not complete the number of projects anticipated because funds were reprogrammed for security.’36 Created by the US Congress in late 2004, the SIGIR began releasing reports and audits of US reconstruction efforts in early 2005. SIGIR estimates that as much as 25 cents out of every US reconstruction dollar in Iraq is now spent on security to protect building sites and contractors. All told, $5.6 billion of the $18.4 billion Iraq Relief and Reconstruction Fund (IRRF) appropriated by Congress in November 2003 had to be reallocated away from reconstruction efforts as part of ‘a new strategy that was more responsive to the new security and political situation in Iraq.’37 Partly due to these cutbacks, the capabilities of the water and electricity sectors remain well below pre-war levels.38
According to the U.S. Department of State’s Weekly Iraq Status Report issued in February 2006, Iraq averaged only 9.3 hours of electricity per day from January 24-30, 2006; residents in Baghdad averaged barely 5.1 hours per day over the same period.39 In comparison, Baghdad averaged 16 to 24 hours of electricity per day prior to the war.40 SIGIR figures show that as of 30 November 2005 only 32% of Iraqis have access to drinking water while a mere 19% have ‘sewerage access’. Prior to the war, 50% of Iraqis had access to drinking water and 24% had ‘sewerage access’.41
Corruption takes its toll
“I saw enormous incompetence… .[The U.S.] was pouring money down the drain.”42
Richard Garfield, a Columbia University health expert and co-author of the Roberts et al. study published in the Lancet

Recent audits and reports to Congress reveal that the rise of the insurgency has not been the only factor impeding US reconstruction efforts. First, there is a lack of fiscal management of IRRF dollars due to a lack of oversight of reconstruction projects. There has also been a damaging overemphasis on ‘achievement indicators’ at the expense of ‘outcome indictors’ in measuring the success or failure of reconstruction in Iraq. According to Dr. Frederick Burkle, senior medical officer on the Disaster Assistance Response Team (DART) for the Office of Foreign Disaster Assistance, USAID in 2003, the US ‘emphasized reconstruction of clinics and hospitals…rather than what these structures were able to do. They put form before function… .It was like their responsibility ended at the door of the structure they rebuilt.’43 As a result, countless completed projects in the water, electricity, and health sectors have been unable to meet the expectations of the Iraqi people. Third, corruption and incompetence have resulted in the loss, waste, and abuse of millions of dollars in critical Iraq reconstruction funds. Some examples include: · In January 2005, the SIGIR told Congress that the CPA could not account for how $8.8 billion of the U.S. administered $37 billion Development Fund for Iraq (DFI) was used.
· The CPA gave one Iraqi ministry enough money to pay 8,026 guards. It was later revealed that only 602 guards actually existed.44
· In April 2003, the US awarded Abt Associates Inc., a Massachusetts-based consulting firm, a $43 million contract to improve the Iraqi Ministry of Health and distribute much needed medical supplies throughout Iraq. However, according to a USAID audit, ‘medical kits intended for 600 clinics contained damaged or useless equipment.’45 USAID eventually cancelled the contract.
Where will the funding come from?
“We were never intending to rebuild Iraq… .We were providing enough funds to jump-start the reconstruction effort in this country.”46
Gen. William H. McCoy, commander of the U.S. Army Crops of Engineers in Iraq

In mid January 2006, US officials revealed that the President did not intend to seek new funds for Iraqi construction in the annual budget request to be presented to Congress in February. Only 20% of the $18.4 billion IRRF earmarked by Congress in 2003 – half of which was ultimately reprogrammed to fight the insurgency, revamp the criminal justice system, and finance the trial of Saddam Hussein - remains to be allocated.47
In addition to the money spent on the water and electricity sectors, the US has spent about $1 billion in an attempt to repair Iraq’s many decrepit hospitals and clinics. As in other sectors, however, as much as 25% of the money has been spent on security.48 In January of this year, Ammar-al-Saffar, Iraq’s deputy health minister, warned that Iraq’s health system would still need $8 billion over the next four years, excluding operational costs, in order to function properly.49
Present donor funds and Iraqi oil revenues cannot pay for the reconstruction of the health system. Despite pledges totaling $13.5 billion for reconstruction from 40 countries at the 2003 Madrid Conference, only about 30% of those pledges have actually been received.50 Iraqi oil production fell by 8% in 2005, and as of December 2005, ‘Iraq was pumping a million barrels a day less than in early 2003.’51
Public health system breaking down
“Crimes against health have been committed for two years in my country, and no one knows about them.”52
Dr. Salam Ismael, Iraqi physician and member of the humanitarian organization Doctors for Iraq.

Public health monitoring has been severely compromised by the lack of security,53 and many people are avoiding the public health sector and turning to the private sector to meet their health needs. According to Dahr Jamail, a journalist who has spent eight months in Iraq, hospitals ‘have become dangerous and broken down.’54 Since April 2003 there have been six health ministers and six US government health representatives. Deputy Minister of Health al-Saffar recently announced that of the 180 health clinics that the US hoped to build by the end of December 2005, only four have been completed and none have opened.55
Nevertheless there have been some positive achievements. Immunization campaigns sponsored by the UN and US have resulted in MMR and polio vaccinations for 5 million and 3 million Iraqi children, respectively.56 Many doctors and nurses have received substantial pay rises57 while the health sector has benefited from the addition of 700 healthcare ‘trainers’.58 The few NGOs and aid organizations that remain in Iraq do remarkable work in the face of overwhelming odds. Most encouragingly, the majority of Iraqis remain fiercely optimistic about the future despite the violence to which they are daily subjected.59
Yet, as the violence continues neutral ‘humanitarian space’ through which to aid the Iraqi people is declining. Dahr Jamail told us that amidst the atmosphere of growing tensions, ‘the public health system is becoming increasingly dangerous….because anytime a man between the ages of 15-50 goes [to a health facility] he could be detained by US or Iraqi security as a potential combatant. This happens often…and is still ongoing.’60 There have also been widespread reports that people from Fallujah, Ramadi, Samarra, and other predominantly Sunni areas have not had equal access to medical care.61 According to Dr. Burkle, the issue of medical neutrality has become more important in the last 20 years.62 So long as public health remains a prisoner of politics, he notes, the ‘ground truth’ will never be brought to light. This update shows that the health situation in Iraq is still in dire straights.
Reference:

1.Russell, Ben and Terri Judd. “Britain could begin Iraq pulling out of Iraq in May, US General reveals.” The Independent, 6 February 2006, pg. 6.
2.“Iraq: Insurgent attacks rose in 2005 says, U.S. military report.” UN Integrated Regional Information Network, 24 January 2006. Available at: http://www.irinnews.org/report.asp?ReportID=51304&SelectRegion=Middle_East
3.Brookings Institution Iraq Index, 13 February 2006, pg. 16. Available at: http://www.brookings.edu/iraqindex
4.Brookings Institution Iraq Index, 13 February 2006, pg. 20. Available at: http://www.brookings.edu/iraqindex
5.Pincus, Walter. “USAID Paper Details Security Crisis in Iraq.” The Washington Post, 17 January 2006, Page A13.
6.Ibid
7.Guterman, Lila. “Researchers Who Rushed Into Print a Study of Iraqi Civilian Deaths Now Wonder Why it was Ignored.” The Chronicle of Higher Education, 27 January 2005. Available at: http://chronicle.com/free/2005/01/2005012701n.htm
8.Rowson, Mike and John Slobada. “No Excuses.” The Guardian, 9 December 2004.
9.Tavernise, Sabrina. “Iraqi death toll exceeded 800 a month, data shows.” The International Herald Tribune, 15 July 2005.
10.Tavernise, Sabrina. “U.S. Quietly Issues Estimate of Iraqi Civilian Casualties.” The New York Times, 30 October 2005. According to a small graphic in a quarterly report to Congress entitled “Measuring Security and Stability in Iraq,” the Defense Department noted that whereas insurgent violence killed or wounded 40 Iraqi civilians and security forces per day at the end of 2004, by the end of August 2005 the rate had increased to 63 a day. All told, the Pentagon estimated that nearly 26,000 Iraqis were killed or wounded from January 1, 2004 to September 16, 2005. Much like the Health Ministry’s count, however, the graph was silent on how many casualties were caused by U.S. and coalition forces. The report also failed to explain how these numbers were arrived at.
11.Baker, Peter. “Bush Estimates Iraqi Death Toll in War at 30,000.” The Washington Post, 12 December 2005.
12.Elliot, G. “Flaws in the calculation of Iraqi war dead.” The Guardian, 10 November 2005.
13.“Burying the Lancet – Part 2.” 6 September 2005. Available at:
http://www.medialens.org/alerts/05/050906_burying_the_lancet_part2.php
14.See the Iraq Coalition Casualties website at http://icasualties.org/oif/IraqiDeaths.aspx for detailed figures on both U.S. and Iraqi casualties.
15.Figures are as of 20 March 2006. See http://icasualties.org/oif/
16.“Iraq – Middle East: Street children face hunger and abuse.” UN Integrated Regional Information Network, 26 December 2005. Available at: http://www.irinnews.org/report.asp?ReportID=50850&SelectRegion=Middle_East
17.Personal correspondence with a source at the World Bank on 6 February 2006.
18.“Iraq – Middle East: Street children face hunger and abuse.” UN Integrated Regional Information Network, 26 December 2005. Available at: http://www.irinnews.org/report.asp?ReportID=50850&SelectRegion=Middle_East
19.Miller, T. Christian. “U.S. Priorities Set Back Its Healthcare Goals in Iraq.” The Los Angeles Times, October 30, 2005 .
20.Ibid
21.“Iraq: Children’s mental health affected by insecurity, say specialists.” UN Integrated Regional Information Network, 7 February 2006. Available at:
http://www.plusnews.org/report.asp?ReportID=51573&SelectRegion=Middle_East &SelectCountry=IRAQ
22.Ibid
23.Ibid
24.Ibid
25.Buncombe, Andrew. “‘Marlboro Man’ turns against war he symbolized.” The Independent, 2 February 2006.
26.Tavernise, Sabrina. “Facing Chaos, Iraqi Doctors Are Quitting.” The New York Times, 30 May 2005.
27.Miller, T. Christian. “U.S. Priorities Set Back Its Healthcare Goals in Iraq.” The Los Angeles Times, 30 October 2005.
28.Personal correspondence with Dahr Jamail on 23 January 2006.
29.Tavernise, Sabrina. “Facing Chaos, Iraqi Doctors Are Quitting.” The New York Times, 30 May 2005.
30.Johnson, Scott. “Doctors in the Cross Hairs.” Newsweek, 9 January 2006. Available at:
http://www.msnbc.msn.com/id/10655555/site/newsweek/
31.Sruck, Doug. “Professionals Fleeing Iraq As Violence, Threats Persist.” The Washington Post, 23 January 2006.
32.Personal correspondence with a Gerri Haynes, a former resident of Baghdad, 7 February 2006.
33.Personal correspondence with a source in Basra, 24 January 2006.
34.According to our source in Basra, one I.V. cannula reportedly costs 5000 Iraqi dinar on the black market, which is equivalent to about 2.8 euros. In comparison, the aid worker we contacted buys them from abroad at the rate of 13 euro cents per cannula.
35.Tavernise, Sabrina. “Facing Chaos, Iraqi Doctors Are Quitting.” The New York Times, 30 May 2005.
36.SIGIR Quarterly and Semiannual Report to Congress, 30 January 2006, pg. 4. Available at:
http://www.sigir.mil/reports/quarterlyreports/Jan06/Default.aspx
37.Ibid
38.425 projects were originally planned in the Electricity Sector. However, only 300 (70.5%) will be completed. Funding for this sector dropped from $5.560 billion to $4.309 billion (a 22.5% decrease) due to reallocations to other sectors. As of October 2005, only $1.65 billion had actually been spent on the Electricity Sector. 136 projects were originally planned in the Water Sector. However, only 49 (36%) will be completed. Funding for this sector dropped from $4.3 billion to $2.1 billion (a 51.2% decrease) due to reallocations to other sectors. As of October 2005, only $.40 billion had actually been spent on the Water Sector. See SIGIR Quarterly and Semiannual Report to Congress, 30 January 2006, pg. 4. Available at: http://www.sigir.mil/reports/quarterlyreports/Jan06/Default.aspx
39.Iraq Weekly Status Report, 1 February 2006, Bureau of Near Eastern Affairs, US Department of State. Available at: http://www.state.gov/p/nea/rls/rpt/iraqstatus/2006/c16536.htm.
40.SIGIR Quarterly and Semiannual Report to Congress, 30 January 2006, pg. 17. Available at:
http://www.sigir.mil/reports/quarterlyreports/Jan06/Default.aspx
41.Ibid, pg. 33.
42.Miller, T. Christian. “U.S. Priorities Set Back Its Healthcare Goals in Iraq.” The Los Angeles Times, 30 October 2005.
43.Personal correspondence with Dr. Fredrick Burkle, 3 February 2006.
44.Ibid
45.Miller, T. Christian. “U.S. Priorities Set Back Its Healthcare Goals in Iraq.” The Los Angeles Times, 30 October 2005.
46.Smith, Doug and Borzou Daragahi. “‘Marshall Plan’ for Iraq Fades.’” The Los Angeles Times, 15 January 2006.
47.Knickmeyer, Ellen. “U.S. Has End In Sight On Iraq Rebuilding.” The Washington Post, 2 January 2006, pg. A4.
48.Miller, T. Christian. “U.S. Priorities Set Back Its Healthcare Goals in Iraq.” The Los Angeles Times, 30 October 2005.
49.Haynes, Deborah. Agence France-Press (AFP), 11 January 2006.
50.Smith, Doug and Borzou Daragahi. “‘Marshall Plan’ for Iraq Fades.’” The Los Angeles Times, 15 January 2006.
51.Kraul, Chris. “Decline in Oil Output Dims Iraq’s Recovery.” The Los Angeles Times, 25 January 2006.
52.Labonte, Ronaled. “Iraq doctor tells of health crimes.” In the British Medical Journal, Vol. 331, 30 July 2005, pg. 252.
53.Personal correspondence with Dr. Frederick Burkle, 3 February 2006.
54.Personal correspondence with Dahr Jamail on 23 January 2006.
55.Jervis, Rick. “Plan for Clinics in Iraq at Risk.” The USA Today, 1 February 2006.
56.Brookings Institution Iraq Index, 13 February 2006, pg. 36. Available at: http://www.brookings.edu/iraqindex
57.Miller, T. Christian. “U.S. Priorities Set Back Its Healthcare Goals in Iraq.” The Los Angeles Times, 30 October 2005.
58.Brookings Institution Iraq Index, 13 February 2006, pg. 36. Available at: http://www.brookings.edu/iraqindex
59.According to a 31 January 2006 World Public Opinion.org poll, 64% percent of Iraqis believe that Iraq today is generally headed in the right direction. It should be noted, however, that only 6% of Iraqis Sunnis believe that Iraq is headed in the right direction. See Brookings Institution Iraq Index, 13 February 2006, pg. 38.
60.Personal correspondence with Dahr Jamail on 23 January 2006.
61.Ibid
62.Personal correspondence with Dr. Frederick Burkle, 3 February 2006.

Kingston Reif is a US intern who is studying at the London School of Economics. He is a graduate in International Relations at Brown University, Providence, and has done academic work on the US occupation of Iraq.

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Kingston Reif
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