This evidence-based report analyzes, from a public health perspective, the impact of the 2003 war in Iraq on health, the health system, and relief and reconstruction. Health is harmed by conflict-related damage to health-sustaining infrastructure and to the health system, as well as the corrosive effects of conflict-related factors such as poverty, unemployment, disrupted education and low morale. The effects of the war must be measured not only by death and injuries due to weaponry, but by the longer-term, enduring suffering.
The report builds on Medacts two previous reports on health in Iraq (2002 and 2003), which attracted worldwide media attention, and again aims to stimulate debate on the impact of conflict on health, with special reference to Iraq. It describes the deaths and injuries attributable to conflict and violence, and the current pattern of mental and physical illness. It gives an overview of the Iraqi health care system and barriers to good health care, including problems with the health-sustaining infrastructure. It analyzes the challenges of building a new health system freely available to all and based on primary health care principles.
A recent scientific study has suggested that upwards of 100,000 Iraqis may have died since the 2003 coalition invasion, mostly from violence, mainly air strikes by coalition forces. Most of those reportedly killed by coalition forces were women and children. Many thousands of conflict-related injuries were also sustained. Infant mortality has risen because of lack of access to skilled help in childbirth, as well as because of violence.
Iraq already had high child and adult mortality and there is an alarming recurrence of previously well-controlled communicable diseases including diarrhoeal diseases, acute respiratory infections and typhoid, particularly among children. There is also a greater burden of noncommunicable disease, but a lack of resources, facilities and expertise to reverse the trends. The likely consequence will be an additional burden of preventable death and disability.
Behavioural problems such as family violence, child and spouse abuse and acts of public violence greatly increase in conflict and post-conflict situations. The aggregated effects of the psychosocial trauma suffered by Iraqi people create preconditions for further violence.
The health-sustaining infrastructure
The Iraqi infrastructure has been severely and repeatedly damaged by over 20 years of war, neglect and mismanagement, economic collapse and sanctions. This has a direct and indirect impact on health as water and sanitation, power supply, food security, housing, transport and many other factors are important health determinants. One in four people still depend on food aid and there are more children underweight (17%) or chronically malnourished (32%) than in 2000, though acute malnutrition has fallen slightly.
The health system all activities whose primary purpose is to promote, restore or maintain health is in disrepair. The quality of state services is poor owing to chronic underfunding, poor physical infrastructure, shortage and mismanagement of supplies, staff shortages and lack of modern skills and knowledge. The 2004 budget allocation to the Iraq Ministry of Health is only US$38 per citizen. People increasingly rely on self-diagnosis and traditional healing, and buy prescription medicines in the marketplace. Under-the-table payments are required to secure many services, and there is widespread suspicion of criminal involvement in the distribution of pharmaceutical supplies. Health workers are trying to provide services in extremely difficult circumstances.
The UN, traditionally responsible for coordinating humanitarian crisis responses, has been marginalised while US assistance has been characterized by damaging political in-fighting. Although project funding has been agreed, little money has been disbursed and many projects have not been implemented. Aid and development workers, both Iraqi and foreign, run great risks and most humanitarian agencies have left central and southern Iraq, which remains largely a war zone. The pursuit of a relief and development agenda may be little more than nominal.
Key recommendations (full recommendations available on p. 12 of the report)
Protecting health in conflict
Long-term interventions to improve health and peace
The 2003 war exacerbated the threats to health already created by previous wars, tyranny and sanctions. Its direct and indirect impacts have probably damaged the material and mental ability of Iraqi society to reverse health decline. Conflict, criminality, social inequality, lack of democratic processes, political instability, presence of foreign military forces and decrepit essential infrastructure combine to damage health and arrest the development of a decentralised, primary care-based health system. There is a grave and immediate threat to the health of the Iraqi people, on top of their current sufferings. The need to find alternatives to violence and to resolve political differences peacefully could not be more urgent.
- Strengthen stewardship roles, capacity and funding to rebuild an Iraqi health system that is free at the point of delivery and based on primary health care principles.
- Require occupying forces to monitor casualties and civilian protection, re-evaluate the impact of weaponry in populated areas, comply with the Geneva Conventions, and ensure health services are accessible to civilians in conflict areas.
- An independent commission should make a thorough investigation of casualties and the state of health in Iraq.