Global Policy Forum

By Dr. Bert De Belder

Iraq's health status, four years into the occupation, is nothing short of disastrous. Iraq's health index has deteriorated to a level not seen since the 1950s, says Joseph Chamie, former director of the United Nation's Population Division and an Iraq specialist.[1] People's health status is determined by social, economic and environmental factors much more than by the availability of healthcare. Not surprisingly, all these factors have deteriorated in the course of the occupation.

A recent UNDP-backed study reveals that one-third of Iraqis live in poverty, with more than 5 per cent living in abject poverty. The UN agency observes that this contrasts starkly with the country's thriving middle-income economy of the 1970s and 1980s.[2] But these figures may well be a grave underestimation, as other reports speak of eight million out of 28 million Iraqis living in extreme poverty on incomes of less than 1 dollar per day.[3] More than 500,000 Baghdad residents get water only for a few hours a day. Most Iraqis get three hours of electricity a day, in contrast to pre-war levels of about 20 hours.[4]

The devastated health of Iraqi children

The combination of sanctions, war and occupation has resulted in Iraq showing the world's worst evolution in child mortality rate: from an under-five mortality rate of 50 per 1000 live births in 1990, to 125 in 2005. That means an annual deterioration of 6.1 per cent - a world record, well behind very poor and AIDS-affected Botswana.[5] At the outset of the 2003 war, the US administration pledged to cut Iraq's child mortality rate in half by 2005. But the rate has continued to worsen, to 130 in 2006, according to Iraqi Health Ministry figures.[6]

Nutrition is, of course, vital to health. According to the United Nations Children's Agency (UNICEF), about one in 10 Iraqi children under five are underweight (acutely malnourished) and one in five are short for their age (chronically malnourished). But this is only the tip of the iceberg, according to Claire Hajaj, communications officer at the UNICEF Iraq Support Centre in Amman (ISCA). "Many Iraqi children may also be suffering from 'hidden hunger' - deficiencies in critical vitamins and minerals that are the building blocks for children's physical and intellectual development," Hajaj says. "These deficiencies are hard to measure, but they make children much more vulnerable to illness and less likely to thrive at school."[7] Hayder Hussainy, a senior official at the Iraqi Ministry of Health, states that approximately 50 per cent of Iraqi children suffer from some form of malnourishment.[8]

Also important is the psychological impact of war and occupation. In a study entitled "Psychological effects of war on Iraqis", the Association of Iraqi Psychologists (AIP) reports that out of 2,000 people interviewed in all 18 Iraqi provinces, 92 per cent said they feared being killed in an explosion. Some 60 per cent of those interviewed said the level of violence had caused them to have panic attacks, which prevented them from going out because they feared they would be the next victims.[9] The API also surveyed over 1,000 children across Iraq and found that 92 per cent of children examined had learning impediments, largely attributable to the current climate of fear and insecurity. "The only thing they have on their minds are guns, bullets, death and a fear of the US occupation," says API's Marwan Abdullah.[10]

Hospitals and clinics faced with a critical lack of resources

On 19 January 2007, a group of some 100 eminent UK doctors signed a letter to British Prime Minister Tony Blair to voice their grave concern over the fate of Iraq's children. The statement read: "We are concerned that children are dying in Iraq for want of medical treatment. Sick or injured children, who could otherwise be treated by simple means, are left to die in their hundreds because they do not have access to basic medicines or other resources. Children who have lost hands, feet, and limbs are left without prostheses. Children with grave psychological distress are left untreated."[11]

The Iraq Medical Association reports that 90 per cent of the almost 180 hospitals in Iraq lack essential equipment.[12] At Yarmouk Hospital, one of the busiest hospitals in Baghdad, five people die on average every day because medics and nurses don't have the equipment to treat common ills and accidents, according to Yarmouk doctor Husam Abud. That translates to more than 1,800 preventable deaths in a year in that hospital alone.[13] Hassan Abdullah, a senior health official in the Basra governorate, says that information suggests that from January to July 2006, about 90 children died in Basra as result of the lack of medicine, a worse figure than for the same period last year, when some 40 children died for similar reasons. Marie Fernandez, a spokeswoman for the Vienna-based aid agency Saving Children from War, deplores the lack of essential supplies, especially intravenous infusions and blood bags. "Children are dying because there are no blood bags available," says Fernandez.[14]

Hospitals subject to military attacks and occupation

"The Geneva Conventions state that hospital are and should remain neutral and accessible to everybody, particularly civilians. Yet, when it's occupied by armed groups or official forces, people don't have this free and humanitarian access," says Cedric Turlan, information officer for the Coordinating Committee in Iraq (NCCI) NGO. His observation is corroborated by numerous reports and sources.

In the first week of November 2006, in Ramadi, some 115 kilometres west of Baghdad, 13 civilians entering the hospital to get treatment were killed by snipers. Less than 10 per cent of the hospital's staff was still working there when US-led forces burst into the hospital many times day and night, looking for snipers on the hospital's roof. "The multinational forces were outside, surrounding the hospital, but they intruded into the hospital on a daily basis," Turlan said. "Now people rarely go to the hospital because they fear being shot or arrested." For several months now, patients have refrained from using the hospital for fear of being shot by snipers or by US-led forces. According to other reports received by NCCI, military forces have also occupied Mosul Hospital, and ambulances have been attacked regularly in Najaf, Fallujah and other parts of Anbar.[15]

On 7 December 2006, there was yet another US military raid at the Fallujah General Hospital that had suffered similar attacks during various US siege operations in the city in April and November 2004. Eyewitnesses said US soldiers raided the hospital "as if it were a military target". Doctors and medical staff were arrested, insulted and called terrorists. A hospital employee said that it was already the third time he was handcuffed by US soldiers, and alleged that "they have been more vicious with medical staff than with others because they consider us the first supporters of those they call terrorists." US Lt Col Bryan Salas, spokesperson of the multinational forces in Iraq, had a quite different explanation: "Coalition forces searched the hospital to ensure that it continues to be a safe place for the citizens of Fallujah to receive the medical treatment they deserve." After the US military raid, the hospital remained closed for several days.[16]

With current Minister of Health Ali Al-Shimari belonging to the political movement of Moqtada Al-Sadr, the latter's military arm, the Mahdi Army, is acting inside hospitals with impunity. Sick and wounded patients have been abducted from public hospitals and later killed. As a consequence, more and more Iraqis are avoiding hospitals. "We would prefer to die instead of going to the hospital," says Abu Nasr, a resident of a Baghdad suburb. "The hospitals have become killing fields."[17]

The ministry also appears to discriminate in the provision of supplies. Tariq Hiali, a health official in Baqouba (60 kilometres northeast of Baghdad), laments that "the Ministry of Health is not providing us with medications and medical equipment - they consider us to be terrorists." An employee at Baqouba's blood bank, Jamal Qadoori, says: "Ambulances we send to Baghdad are being intercepted by the Mahdi Army."[18]

The emergency unit in the Basra Teaching Hospital was closed for five months after unidentified assailants killed a number of doctors working there. Now many doctors and nurses refuse to go to work, fearing for their lives.[19] Likewise, clinics have shut down in Ramadi, Hit, Haditha and Fallujah. The Institute for War and Peace reports that in Baghdad, those doctors still practicing have moved their clinics into residential areas or inside medical compounds for safety reasons. They only open in the morning, because of curfews and poor security.[20]

Health workers harassed, arrested, kidnapped and assassinated

Under the Fourth Geneva Convention, Article 18 reads: "Civilian hospitals organised to care for the wounded and sick, infirm and maternity cases, may in no circumstances be the object of attack, but shall at all times be respected and protected by the Parties to the conflict." On-the-ground reality in Iraq today is quite different.

"A major problem affecting Iraq's health sector is the country's desperate security situation," says Nada Doumani, a spokeswoman for the International Committee of the Red Cross (ICRC). "Armed men storm operating theatres forcing doctors to treat their patients they bring as a priority. Some patients insist on keeping their arms and masks while being treated. This creates a traumatising situation for the doctors," she says.[21]

Examples abound. Dr Washdi Mahmoud works in the Ibn Al-Nafees Hospital, the largest cardio-vascular centre in Baghdad. Via telephone from Baghdad on 27 February 2006, he told us: "Yesterday morning, we were threatened by the relatives of patients. They even pointed a gun at one doctor's head! The hospital's security guards didn't bother to intervene, so we decided to go on strike."[22] Dr Salam Ismael of the Doctors for Iraq society explains: "We are harassed by militias of certain political parties. The government is not acting on them. They enter the patient's rooms with their weapons, they shout at the doctors, they threaten to kill them."[23]

Doctors for Iraq received reports that armed gunmen had entered Tel Afar Hospital in the northwest of Iraq on 9 May 2006 and threatened and attacked staff and patients waiting to be treated. A doctor described how one of the armed men put a gun to his head demanding that he stop treating a wounded child and instead attend to a man with a minor shell wound in his leg. The armed group started vandalising and breaking hospital equipment and then attacked an ambulance driver, breaking his arm with a rifle butt. Another ambulance driver was punched in the face, and three armed men attacked the hospital pharmacist, taking turns in hitting and kicking him. One of the armed men fired bullets above a doctor's head, missing him narrowly and causing fear and hysteria in the hospital.[24]

On 28 September 2006, doctors at Baghdad's Yarmouk Hospital went on strike after Iraqi police burst into the facility and forced doctors to treat a wounded colleague, while brandishing their guns. The doctors called on the Interior Ministry to enforce a complete weapons ban in the hospital.[25] Early November 2006, Dr Ibrahim Abdel-Sattar, a cardiologist in Baghdad, reported: "My colleague was killed while he was attending one of his patients two weeks ago. The armed gang broke into his clinic, shot him dead and left without explanation."[26]

As if the daily violence was not enough, in the chaos and disorder that reign in occupied Iraq, health professionals are also prone to getting kidnapped for ransom. On 9 November, men reportedly wearing blue police uniforms kidnapped the head of Iraqi Red Crescent Society (IRCS) administration, Dr Anas Al-Azawi, in front of his house. The price for his freedom was set at $750,000, but he was released after a lesser ransom was paid. On 17 December, armed men allegedly wearing Iraqi Army uniforms stormed the office of the IRCS in Baghdad and abducted 42 people. 26 employees IRCS employees, both Shia and Sunni, were later released.[27]

Peter Kandela, an Iraqi doctor working in the United Kingdom, interviewed Iraqi medical staff that had fled to Jordan and Syria. He recounts the story of a kidney surgeon seized by a group of armed men whose first act was to go through his address book to look for other potential victims. "They had the audacity to suggest that in return for receiving better treatment in captivity, I should recommend others for kidnapping," the surgeon said. He was released after his wife paid a ransom of $250,000.[28] Dr Kandela also explained that "in the new Iraq, there is a price tag linked to your position and status. Those doctors who have stayed in the country know what they are worth in kidnapping terms, and ensure their relatives have easy access to the necessary funds to secure their speedy release if they are taken."[29]

Dr Omer, a cardiovascular surgeon, left his job in Baghdad and is now working as a general practitioner in a primary health care clinic in Syria. "What could I do?" he asks, "I was threatened by armed militias inside the hospital. Three surgeons had been killed already and there were only three of us left. I couldn't be the next target as I have a child to raise." Dr Omer was forced to flee Iraq. He added: "I am not happy with what I am doing here in Syria. I was a specialist doctor and now I am working as a junior doctor. It is as if you were asking an officer to work as a soldier."[30]

A massive flight of health professionals

In March 2006, the British NGO Medact said that 18,000 out of Iraq's 34,000 physicians had left the country since the onset of the war, according to official figures from the Iraq Medical Association (IMA). Farouk Najji, a clinician and senior member of IMA, declares: "About 2,000 physicians have been killed since 2003. The violence has increased and everyday we are losing the best professionals in Iraq." In some cases, ambulances picking up the injured after explosions are without paramedics or nurses, Najji says. "There are not enough professionals and the ones available are in hospitals, trying to figure out how to treat patients in improvised operating theatres," he adds.[31]

A shortage of doctors and nurses has also been reported in Basra. According to health official Hassan Abdullah, there are no reliable statistics on how many doctors, dentists, pharmacists and nurses have left the area, but unofficial data suggests that at least 200 health professionals have left since January alone.[32] Some of them try to get more secure employment elsewhere in Iraq. Rezan Sayda, a senior official in the Kurdistan Regional Government's health ministry, said last December that her ministry had employed 600 doctors who had fled insecure parts of the country, and that another 320 were on the waiting list for employment.[33]

The lack of health personnel has disastrous consequences for the health of local patients. Writing in the British Medical Journal, Dr Bassim Al-Sheibani and two colleagues from the Diwaniyah College of Medicine in Iraq report that, "medical staff admit that more than half of those who died could have been saved if trained and experienced staff were available."[34]

Reconstruction under occupation: A dismal failure

Four years into the US-led war on Iraq, the country's healthcare system is in a shambles. Most hospitals lack basis supplies, dozens of clinics remain incompletely constructed, and costly high-technology equipment lies idle in warehouses. Since 2003, US agencies may have spent up to $1 billion of Iraqi reconstruction funds on healthcare, but no new hospitals and only a few local clinics have been built. Even the pet project of First Lady Laura Bush - a $50 million state-of-the-art children's hospital in Basra - is running far behind schedule and over budget.[35]

According to Amar Al-Saffar, an official in charge of construction at the Iraqi Health Ministry, not a single hospital has been built in Iraq since Al-Khadimiyah Hospital opened in 1986 in Baghdad.[36]

A $200 million reconstruction project for building 142 primary healthcare centres ran out of cash in early 2006, with just 20 centres on course to be completed, an outcome the World Health Organisation described as "shocking".[37]

In a damaging report, CorpWatch harshly criticises the US-led reconstruction of Iraq's health infrastructure, demonstrating how US companies such as Parsons Global, Abt Associates and Bechtel did little more than take the money and run.[38] Those companies were awarded huge reconstruction contracts - a $70 million contract for Parsons, $43 million for Abt Associates and $50 million for Bechtel - while effectively sidelining experienced UN agencies as UNICEF and WHO.

In April 2006, the US Army Corps of Engineers that was supposed to construct 150 primary healthcare centres decided to cancel the construction of 130 of them. The construction had been contracted out to Parsons Global and by the time the US Army Corps cancelled Parsons' contract only six clinics had been completed. Meanwhile, 150 sets of medical equipment had already been ordered and warehoused at Abu Ghraib. Thus, 130 sets are intended for clinics that will never see the light of day. Further, it was found that 46 per cent of the stock contained missing or damaged crates, or boxes that were mislabelled or not labelled at all.

Abt Associates was contracted to repair existing Iraqi hospitals but nothing of the sort happened, the company handing the job over to local sub-contractors who were inexperienced or corrupt. When, in April 2004, the security situation in Iraq turned from bad to worse, Abt Associates staff left the country. $20.7 million of US taxpayers' money had already been paid to Abt Associates through USAID.

Laura Bush's showcase children's hospital in Basra, a project awarded to Bechtel, went much the same way. The hospital was slated to feature 94 beds, private cancer suits, CATS scans and other high tech equipment necessary to treat childhood cancer in a region highly affected by depleted uranium following the first Gulf War. The price tag rose from $50 million to $170 million and in July 2006 Bechtel was asked to withdraw from the project. It remains on hold.

Four years after its onset, it has become clearer than ever that the US-led war and occupation of Iraq have resulted in a massive public health disaster for Iraqis. Reversing the current trend of ever-deteriorating health conditions requires first and foremost the end of the occupation.

[1] The Los Angeles Times, 15 November 2006

[2] 18 February, 2007, http://siteresources.worldbank.org/IRFFI/Resources/ExSumLivingStandardIraq3.pdf

[3] The Los Angeles Times, 15 November 2006

[4] IRIN, 28 January 2007

[5] UNICEF, The State of the World's Children 2007

[6] The Los Angeles Times, 15 November 2006

[7] IRIN, 5 March 2007

[8] Medact, Iraq Health Update, March 2006

[9] IRIN, 31 January 2007

[10] David Wilson, The Collapse of Iraq's Health Care System, http://www.counterpunch.org/wilson10162006.html, October 14-15, 2006

[11] The Independent, 20 January 2007

[12] IPS, 26 November 2006

[13] The Los Angeles Times, 15 November 2006

[14] IRIN, 9 July 2006

[15] IRIN, 13 February 2007

[16] IPS, 14 December 2006

[17] The Washington Post, 30 August 2006

[18] The Los Angeles Times, 15 November 2006

[19] IRIN, 9 July 2006

[20] IPS, 14 December 2006

[21] IRIN, 28 January 2007

[22] Telephone conversation, 27 February 2006

[23] Telephone conversation, 27 February 2006

[24] http://www.health-now.org/site/article.php?menuId=14&articleId=632

[25] The San Francisco Chronicle, 30 September 2006

[26] IRIN, 7 November 2006

[27] UN Assistance Mission for Iraq (UNAMI), Human Rights Report, 1 November-31 December 2006

[28] The Independent, 20 October 2006

[29] The Times, 20 October 2006

[30] Communication of Dr Salam Ismael, 26 February 2007

[31] IRIN, 7 November 2006

[32] IRIN, 9 July 2006

[33] IPS, 6 December 2006

[34] British Medical Journal, 20 October 2006

[35] The Los Angeles Times, 15 November 2006

[36] The Times, 21 October 2006

[37] The Independent, 20 October 2006

[38] High-Tech Healthcare in Iraq, Minus the Healthcare. Pratap Chatterjee, CorpWatch, 8 January 2007