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The Crisis in Iraq

Submitted by Richard Garfield RN DrPH

Tags: conflict crisis iraq

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Elissa Dresden RN ND, Postdoctoral Research Trainee,
University of Illinois at Chicago College of Nursing Global Health Leadership Office
 
Richard Garfield RN DrPH

Henrik Bendixen Professor of Clinical International Nursing, Columbia University
Visiting Professor, London School of Hygiene and Tropical Medicine

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ABSTRACT

The impending military conflict in Iraq will significantly affect the current capacities of the Iraqi health system.  The health system in Iraq has undergone incredible stressors during the past two decades.  Health professionals can better connect with their Iraqi colleagues through understanding the specific context of the upcoming crisis.  Drawing from several sources, including first hand accounts from six Iraq visits in the last five years and consulting for several NGOs and UN organizations, this article provides a brief introduction to the Iraqi context, highlighting both the strengths and needs of the Iraqi health system. 

The Context of Crisis

Nurses for or against war, on military bases or in demonstrations in cities across the country want to understand the health consequences of such military action.  What effects will war have on the Iraqi civilian population?  What resources will Iraqi nurses and doctors have with which to cope?  What about biological and chemical weaponry?  Most available information presents first-hand accounts of visits to a hospital ward. Such anecdotal information lacks social, cultural, and historical contextualization (Akunjee, 2002; Barnouti, 1996; Kandela, 1999).  In conducting these first-hand accounts, the access to data is limited and verification is rare (Garfield, Zaidi & Lennock, 1997).  There have been editorials calling on physicians to respond (Editorial, 2002), and appeals from the Iraqi Medical Association for medical textbooks and journals (Al-Araji, 2001).  As a polarizing political issue, it is important for nurses to become well informed.

Representations of Iraq in the popular media focus predominantly on biological and chemical weaponry and on the effects of sanctions on health.  There is a lack of focus on the daily lives of working health professionals and the public health consequences of military action.  Rather than fostering a shared sense of humanity, sensational news generally encourages a greater sense of distance from the affected people.  One can become connected to the lived realities by supporting the provision of U.S. led humanitarian aid.  Yet the humanitarian aid response has been criticized for its lack of attention to social, cultural and historical factors, lacking in activities such as involving local participants and conducting thorough needs assessments (Griekspoor & Sondorp, 2001; People In Aid, 2003). 

It is likely that in the coming months US health professionals along with engineers, logisticians, and other humanitarian aid personnel will travel to Iraq toward the aims of alleviating suffering, rebuilding systems and structures, and preventing further death and destruction.  Most of the individuals and organizations will be largely unaware of current Iraqi health system capacities and strengths.  Drawing from several sources, including first hand accounts from six Iraq visits in the last five years and consulting for several NGOs and UN organizations, this article provides a brief introduction to the Iraqi context, highlighting both the strengths and needs of the Iraqi health system.

From the “cradle of civilization” to modern war

The modern state of Iraq was created in 1920. The history of this area and its people dates back over 10,000 years.  Ancient civilizations such as the Sumerian, Babylonian, and Parthian cultures thrived in this area when it was known as Mesopotamia (meaning between the rivers – the Tigris and Euphrates).  Mesopotamia is considered to be where the first alphabet and primitive calendars were developed and has been called the “cradle of civilization”.  Muslims took over this land in 7th century and Baghdad becoming the capital for the Abassid caliphate in the 8th century.  At this time Baghdad was recognized as one of the world’s greatest cities, famous for its architecture, libraries, and culture.  Much of the culture was destroyed by the Mongols in the late 13th century.  Iraq then became part of the Ottoman Empire from the 16th century until the end of the World War I.

The modern state of Iraq was created as part of a peace settlement when the Allies divided the former Ottoman Empire.  The League of Nations granted this area under an international trusteeship to Britain.  Since 1921, the Hashemite King Faisal Ibn Hussein Mecca reigned.  When Iraq became an independent kingdom in 1932, he continued this reign.  In 1958, following several changes in government that led to the rise of the Ba’ath Socialist Party, Iraq became a Republic.  Following nationalization of the country’s oil industry in the 1970s Iraq rapidly developed in sectors such as economics, health, education, and politics.  Following years of internal political strife, Iraq became embroiled in war with Iran from 1980-1988.  In 1991 Iraq was at war with a wide coalition of countries, led by the United States, during the Gulf War. UN economic sanctions were put in place in 1990 and continue to this day.

Diverse people, changing economies

Iraqi people and culture reflect a diverse array of ethnic, religious and tribal groups and perspectives.  With the growth of the oil industry, increasing educational opportunities, and a strengthening centralized Baghdad, Iraq became a modern cosmopolitan society with an urban culture, a high level of formal education, architecture and art integrated with local cultural traditions.  According to the 1997 Census, around 68% of Iraqis live in urban areas.  

In an area approximately the size of California, there are about 26 million people.  Of these, 75% are ethnically Arabs, 15-20% are Kurds, and the remaining 5% are Turkman, Assyrian or other (U.S. Department of State, 2001).  Different religious groups coexist in Iraq: sixty percent are Shia Muslim; thirty-five percent are Sunni Muslim; five percent are Christian.  Arabic is the most commonly spoken language, with Kurdish being spoken predominantly in the North. 

Prior to the Iran-Iraq war, Iraq had oil revenues of more than $20 billion a year and $35 billion in foreign exchange reserves.  The Iran-Iraq war crippled the economy, depleting reserves and amassing a foreign debt of more than $40 billion.  Infrastructure and economy were destroyed further in the 1991 Gulf war and few repairs occurred under the sanctions regime of the 1990s.

Economic sanctions and the oil-for-food program

In August of 1990 the UN imposed economic sanctions on Iraq.  This in effect blocked most commercial imports and exports, froze known Iraqi international funds, and severely restricted travel.  The sanctions were rapid and widespread, building on the effects of destroyed public and private infrastructure that were destroyed during the Gulf War (Osborne & Garfield, 2000).  The Gross National Product fell by about 75% from 1990 to 1993.  The gap between those with high and low incomes widened and persisted through the 1990s (Burns, 2002).  In 1997 55% of Iraqis lived in poverty and another 20% lived in extreme poverty (UN Special Topics on social conditions, 1999).  

In 1996 the oil-for-food (OFF) program was initiated to provide funds through the U.N.-administered sales of Iraqi oil to provide humanitarian goods to alleviate this suffering.  It has provided more than $25 billion worth of humanitarian goods to the country, including $3.3 billion to the health sector.  Under very difficult conditions the OFF slowly reduced and eventually reversed many aspects of the stunning decline in social conditions to occur in Iraq in the 1990s (Garfield, 2003a).  Those areas that have improved the most include nutrition and curative medical care, reflecting the improvement in commodity-based efforts.

Before 1990 – health care training, services and indicators

The Iraqi health system prior to 1990 was sophisticated, well-supplied, and based on a full compliment of specialty-trained physicians.  The Iraqi health system is based on the United Kingdom’s National Health System.  It has a six-year British style medical education curriculum with requisite postgraduate residency training.  Both medical education and care was designed to be free, with even medical textbooks being free prior to the sanctions.  Most senior medical faculty trained in British or U.S. hospitals (Richards & Wall, 2000).

Nursing education in Iraq is also free.  Nurses can graduate from intermediate and preparatory schools at age fifteen and eighteen respectively.  In addition, high school science graduates and other selected pupils can attend a two-year technical institute of nursing.  After graduating from the technical institute, a nurse is eligible to apply for further study such as Masters studies in the Baghdad College of Nursing (WHO, 2000).  Yet, before the Gulf War, Iraq employed many foreign nurses (Akunjee & Ali, 2002).

Health indicators during this time reflect a fairly developed health system.  For example, estimated per capita calorie availability per day increased from 1,958 in 1961 to 3,400 during 1984-1990. See Table 1.  Primary health care services were available to large majorities of  urban and rural residents (CESR, 2003).

A health system under duress

The situation for Iraqi health professionals and citizens seeking health care deteriorated in the 1990s.  Food and medicine imports declined by 85-90% following the 1990 sanctions and the 1991 Gulf War.  In addition, physical damage to essential infrastructure such as water and power systems decreased the capacity of the health system.  Iraqi physicians and nurses were faced with diminishing materials and medicines, while the health needs of the population grew. 

Researchers’ visits to Iraq in April 1996 suggest great deterioration of hospital and health center maintenance (Garfield, Zaidi, & Lennock, 1997).  Health professionals were unable to address the increasing numbers of postoperative infections, infectious diseases and nutritional deficiencies.  Physicians and nurses were providing care in places without plumbing, heating, surgical materials, and basic medicines.  By 1997, services from the public system of medical care such as x-rays, lab tests, surgical procedures and prescriptions decreased to half in comparison to 1990 (Garfield, Zaidi & Lennock, 2000; UN, 1998). 

Prior to the OFF program, health indicators reflected serious changes in health status, particularly for children.  For example, the number of diarrhea episodes among under five year olds rose from 3.8 in 1991 to 14.4 per year in 1996 (UNICEF, 2002).  In the mid-1990s, an estimated 70% of child deaths were due to diarrhea or respiratory disease.  Mortality among children under age five more than doubled in the 1990s in the Center and South of the country.  

Since the OFF program there has been improvement in most aspects of Iraq’s health system.  Materials such as essential medicines, x-rays, and ambulances become more available.  Health related visits increased due to the improved access to some medicines, with subsequent improved health indicators.  The number of reported diarrhea cases declined by 19% from 1999 to 2002.

The system in 2002 had 583 primary health care centers (formerly 900), 45 public hospitals, and 1000 ambulances.  Availability of essential medicines at pharmacies rose from 40% in 1997 to 80% in 2002.  By 2002, surgical operations rose by 40% and lab tests rose by 25% in comparison to 1997.  Increasing rations, declining food prices, and increasing incomes combined to reduce malnutrition among under fives to levels in 2002 that were similar to those in 1991 (UNICEF, 2002).

 The flow of imported commodities has been the base of improvements to the health system in recent years. Funds from the OFF program cannot, however, be used for training or employing people.  The physical structures are still deteriorating due to very limited resources for maintenance and upkeep.  Nurses, physicians and other health professionals do not receive educational or technical updates in modern techniques.  Students have much difficulty acquiring basic textbooks and the library resources have dwindled.  The Iraqi population receives very little public health promotion as the Ministry of Health promoted only limited programs on topics such as nutrition and sanitation education (Garfield, 2003a). 

Limitations in staffing for the public health system are severe.  While some physicians are maintaining satisfactory income levels due to income derived from private practice, nurses lack this option.  Foreign nurses staffed most of the health system in the 1980s; they left with the Gulf war of 1991 and have not returned. Many Iraqi nurses have left the hospitals and their profession, choosing more renumerative employment or emigration in the 1990s.  This leaves family members to provide the majority of bedside care to patients. 

Overall, the Iraqi health system has been in crisis for the last twelve years.  Research is needed into the coping mechanisms and strengths of Iraqi families and society.  Much is yet to be learned about the effects of the sanctions, the OFF program, and national politics on access to health services and other health related behaviors. The OFF program has not offered much relief and resources to the growing problem of poorly trained and unavailable nurses. This limited system is now preparing to care for the assumed masses of injured, traumatized, and dying patients.

Preparing for the worst

Iraqis have learned some lessons about preparing for crisis and conflict in Iraq.  People seem to be more aware of the need to stock months of food and other essential items (Garfield, 2003b).  However good the awareness may be, the Iraqi health system does not appear to have the capacity to cope with the numerous threats that military conflict will bring as emergency medical services have limited abilities and resources (CESR, 2003). The OFF program will be disrupted and a system that has been under duress for over a decade will be expected to cope with known and unknown threats.  Unknown threats include biological, chemical and nuclear weaponry.  Known threats are listed below.

Immediate excess mortality and morbidity

            From the Gulf War, the total excess deaths from all causes during the war and immediately thereafter are estimated at 86,000 men, 40,000 women and 32,000 children (Garfield, 2003b).  Few of these deaths occurred from bombings; most were the result of destroyed infrastructure and civil conflict after military hostilities had finished. Even with current sophisticated precision weapons, there will be excess mortality and morbidity following military conflict. 

Landmines and bombs

A war in Iraq would involve landmines, cluster bombs, and other explosives.  The U.S. is not party to the 1997 Mine Ban Treaty and there are untold numbers of landmines remaining from the Iran-Iraq war.  Landmines cause loss of life and limb to civilians long after the war has ended.  The U.S. and NATO have used cluster bombs in recent conflicts.  These sometimes fail to detonate on impact and are later picked up or stepped on by children and other civilians. The impact will depend on the particular explosive and where they are targeted.  Targets in previous wars have included urban areas, clinics, hospitals, water, and power facilities. 

Damage to essential infrastructure such as water, sanitation and power facilities

            Iraqi health professionals could be confronted with a public health emergency as food, potable water, and access to power decreases or remains inconsistent.  When the U.S. destroys military targets such as the Iraqi command and control systems, power supply throughout the country could be damaged.  Back-up generators that have been serving an estimated 70% of health institutions and water pumping stations require regular fuel and maintenance in order to support some areas if the power supply is down. 

Major disruption in basic supplies

Iraqi people are largely dependent on rations from the OFF program.  Anticipating war, the government of Iraq has been distributing two month rations at a time since July 2002.  Physicians and nurses are reliant on the medical supplies distributed by the OFF program.  It is not yet known whether another distribution program will be in place following military action, or if this will occur before current supplies are exhausted.                       

Population displacement and internal conflict

            There will be population displacement in and around Iraq.  This may be due to both external military action and internal conflicts.  Internally, there may be reprisals against opponents of the current government of Iraq.  In addition, during such widespread instability, some groups may be seeking revenge or independence based on prior conflicts and issues.  In these times large groups search for safety, traveling long and strenuous routes that can result in casualty and illness.

During external or internal conflict, populations move toward refuge.  For Iraqis, there may not be too many places to go.  There remains an excess of three million Iraqi refugees in neighboring Turkey and Iran from over a decade ago. With neighboring areas already hosting so many refugees, they may threaten to close borders, leaving endangered and fleeing Iraqis to seek other areas.  UN organizations are currently planning for large numbers of Internally Displaced Persons. 

Inappropriate or inadequate foreign humanitarian aid

Humanitarian organizations are not prepared for the crisis in Iraq.  Very few organizations have been able to work in Iraq.  There are approximately 100 foreign charity workers and 1000 UN staff on the ground (Garfield, 2003b).  Since sanctions, no U.S. relief organization has been able to work in Iraq.  Moreover, the US Treasury’s Office of Foreign Assets Control has restricted U.S. individuals from traveling to Iraq and Iran.  Intense planning for a massive humanitarian response in Iraq has begun, yet many of the players have little or no current field-based knowledge of conditions in Iraq.  Foreign nurses, physicians, and other aid workers will soon be on the ground. 

The absence of proper field assessment may lead to unnecessary, inappropriate and grossly inadequate response (Noji & Toole, 1997; VanRooyen, Hansch, Curtis, & Burnham,   (2001).  Routine and emergency epidemiology coupled with rich social and historical information can inform and improve humanitarian practice.  International organizations must develop balanced partnerships with Iraqi organizations and individuals in order to overcome the lack of familiarity and knowledge.  As the U.S. commits millions of dollars to humanitarian aid for Iraq following war, health professionals in the U.S. and elsewhere must work to promote a sense of connectedness with Iraqi health professionals in order to combat the impending crises. 
 

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References

1. Akunjee, M.  (2002). Iraq: A health system in crisis. Student BMJ, 10, 294.
2. Akunjee, M. & Ali, A.  (2002). Healthcare under sanctions in Iraq: An elective experience.      Medicine, Conflict & Survival. 18(3), 249-57.
3. Al-Araji, A.  (2001). Iraqi doctors appeal for help from doctors in other countries. BMJ, 323(7303), 53.
4. Banatvala, N. & Zwi, A.B.  (2000). Public health and humanitarian interventions: developing the evidence base.  BMJ, 321, 101-105.
5. Barnouti, H.N.  (1996). Effect of sanctions on surgical practice. BMJ, 313(7070), 1474-5.
6. Burns J. (2002, December 31). Amid Brutal Poverty in Iraq, a favored few enjoy riches. New York Times A1.
7. CESR.  (2003).  The human costs of war in Iraq. Accessed March 13 2003 at             http://www.reliefweb.int/library/documents/2003/cesr-irq-07mar.pdf
8. Daponte, B.O. & Garfield, R.  (2000). The effect of economic sanctions on the mortality of  Iraqi children prior to the 1991 Persian Gulf War. American Journal of Public Health,  90(4), 546-552.
9. Garfield, R. (2003a). Changes in health and well-being in Iraq. Unpublished manuscript.
10. Garfield, R. (2003b). Potential humanitarian impact of war with Iraq. Unpublished manuscript.
11. Garfield, R., Zaidi, S. & Lennock, J. (1997). Medical care in Iraq after six years of sanctions. BMJ, 315 (7120), 1474-1475.
12. Griekspoor, A. & Sondorp, E. (2001). Enhancing the quality of humanitarian assistance: Taking   stock and future initiatives. Prehospital and Disaster Medicine 16(4), 209-215.
13. Kandela, P. (1999). Medical services continue to decline in Iraq.  Lancet, 353(9167), 1861.
14. Kingman, S. (2001). Research briefing:  Nursing a country’s health system back    to health.         Department of Public Health & Policy, London School of Hygiene & Tropical Medicine. Accessed February 7 2003 at https://lshtm.ac.uk/php/publications/briefing4.pdf.
15. Noji, E.K. & Toole, M.J.  (1997). The historical development of public health responses to       disasters. Disasters, 21(4), 366-376.
16. People in Aid:  Promoting best practice in the management and support of aid personnel.           Accessed February 5 2003 at http://www.peopleinaid.org/. 
17. Richards, L.J. & Wall, S.N.  (2000). Iraqi medical education under the intellectual embargo. Lancet, 355(9209), 1093-1094.
18. Editorial (2002). Iraq: Harm reduction through health. Lancet, 360 (9339), 1031.
19. United States Department of State (2001). Background Note: Iraq. Accessed February 7 2003        at  http://www.state.gov/r/pa/ei/bgn/6804.htm.
20. UN Special Topics on Social Conditions in Iraq. (1999).
21. UN Secretary General’s 180 Day Report. (1998, June 5). S/1998/477.
22. UNICEF. Malnutrition down by half among Iraqi children. Baghdad, 2002
23. VanRooyen, M.J., Hansch, S., Curtis, D., & Burnham, G.  (2001). Emerging issues and future needs in humanitarian assistance. Prehospital and Disaster Medicine, 16 (4), 216-222.
24. WHO (2000, November ). Iraq briefing.Accessed February 7 2003 at          www.who.int/disasters/repo/6020.doc.

Table 1

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Address Comments to:

Richard Garfield
Box 30
630 West 168^th Street
NY, NY 10032

212-305-3248
212-305-6937

[email protected]

Acknowledgments

ED wishes to acknowledge the post doctoral funding support of NIH NINR Grant # 7070 T32, Research Training in Primary Health Care.

RG wishes to thank David Cortright, Patricia David, Juan Diaz, Pierre Habshi, Gerald McHugh, Colin Rowat, John Mills, Anupama Rao Singh, Khalid Al-Hiti, Sanjiv Kumar, Wisam Abdul-Rahman, Haydar Nasser, and His Excellency Minister of Health Omid Mubarak for providing information, facilitating data collection, or reviewing text and the Physicians for Social Responsibility, the Center for Social and Economic Rights, the American Friends Service Committee, the University of Baghdad and UNICEF for facilitating travel to Iraq.