Health Effects of the War on the Iraqi People

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Health Effects of the War on the Iraqi People
Physicians for Social Responsibility-Los
Angeles U.S. Affiliate of International
Physicians for the Prevention of Nuclear War
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Physicians for Social Responsibility
Prevent what we cannot cure.
Guided by the values and expertise of medicine
and public health, Physicians for Social
Responsibility works to protect human life from
the gravest threats to health and survival.
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Measuring the wars effect on health

• Historical background
• Immediate and direct
• Indirect
• On health sustaining infrastructure
• Conditions of life

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Historical Background

• Iran-Iraq War 1980-1988
• Invasion of Kuwait
• Gulf War 1991
• UN Sanctions 1990-2003
• Oil-For-Food Program 1996-2003
• Iraq War 2003 -
• Occupation - ongoing
• Insurgency - ongoing

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Iran-Iraq War 1980-1988

• Pres. Reagan sends Donald Rumsfeld as emissary to
  Saddam in December 1983
• U.S. Aids Both Sides

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Invasion of Kuwait
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Gulf War 1991
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Direct Hit on Shelter
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Home Destroyed - Still Smiling
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UN Sanctions 1990-2003
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No Medicines
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Deteriorated Equipment
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Direct Effects of War Death
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How Many Iraqi Civilian Deaths?

• We dont do body counts, General Franks.
• Precise number cannot be known in war zone.

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Iraq Study GroupDecember 7, 2006
in addition, there is significant
underreporting of the violence in Iraq
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The Lancet Study October 2006

• Cluster Sampling
• Crude Mortality Rate 1/02 - 7/06
• Includes 14 mos. prewar 40 mos. during war
• Interviewed 1849 households
• Teams of Iraqi doctors

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Findings of the Lancet Study

• 655,000 excess deaths in Iraq since onset war
  3/03
• Between 393,000-943,000
• 601,000 violent excess deaths
• 64,000 non-violent excess deaths
• Death rate increasing
• 2004gt2003
• 2005gt2004
• 2006gt2005

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Direct Effects Injuries
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How Many Injuries?

• Exact number unknown
• Usual estimate 3X number deaths
• Terrorist bombings may increase no.
• Landmines
• Unexploded ordnance

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Indirect Effects on Health

• Communicable Disease
• Children
• Noncommunicable Disease
• Reproductive Health
• Mental Health

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Communicable Disease

• The magnitude of communicable diseases continues
  to increase, Ministry of Health, 2004
• Diarrheal diseases
• Acute respiratory infections
• Leishmaniasis
• Measles
• Mumps
• Typhoid

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Effects on Children

• Higher rates infant/under five mortality since
  1990
• Improved rates with Oil-For-Food but still
  greater than 1990
• Insecurity/violence/bombings
• Cold chain disruption-vaccine spoilage
• Erratic electricity supply
• Looting
• Lack of equipment
• Erratic supply of vaccines
• Renewed efforts MMR immunization campaign

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Noncommunicable disease

• Poor disease prevention/health promotion
• Poor primary care
• Medication shortages
• Poor outreach to rural and poor populations
• Lack of access due to ongoing violence

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Reproductive Health

• Maternal mortality doubled 1989-1998 - sanctions
• Babies delivered without qualified assistance
  30 urban, 40 rural

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Mental Health

• Increased domestic violence
• Increased spousal abuse
• Increased public violence
• Increased incidence mental/behavioral disorders

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Mental Health

• Poor care - none in primary clinics
• Specialist based
• Two psych hospitals in country - both in Baghdad
• Patients at home - sometimes abused
• Brought to hospital when family cant cope

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Effects on Health Sustaining Infrastructure

• Water and sanitation
• Power supply
• Nutrition
• Health system

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Potable Water Availability

• Pre-war 12.9 Million
• March 2006 9.7 Million
• Source Brookings Institute 11/06

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Water and Sanitation

• Damaged in war
• Looted
• 1/2 sewage treatment plants non-functional
• 500,000 T raw/partially treated sewage into
  rivers daily
• Less than 1/2 pop. rural areas with access
  potable water

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Iraqi Population with Functioning Sewage System

• Before war 6.2 Million
• March 2006 5.6 Million
• Source Brookings Institute 11/06

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Power Supply Oil

• Second greatest oil reserves in world
• Pre-war peak 2.5 M bbl/d
• 2.25 in 2002
• 1.8 in 2005
• 2.04 in November 2006

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Power Supply Electricity

• Extensive damage
• Supplies erratic
• Sufficient for 1/2 potential load
• Current output below prewar levels

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Electricity Availability

• Pre-war
• 4-8 hrs/d nationwide
• 16-24 hrs/d Baghdad
• Nov. 2006
• 11 hrs/d nationwide
• 6.8 hrs/d Baghdad
• Source Brookings Institute Nov. 2006

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Nutrition

• 1/4 population dependent on public food
  distribution
• Public food dist. inadequate for poorest
• 2003 compared to 2002
• 17 more kids underweight
• 32 more kids chronically malnourished

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Health System

• Before 1990
• After 1990 sanctions and First Gulf War 1991
• With Oil-For-Food Program
• With 2003 War, Occupation, Insurgency

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Before 1990

• Government financed - oil income
• Nominal charge to patients
• Evolving primary, secondary, tertiary centers
• Foreign doctors and nurses immigrated
• Iraqi health professionals abroad for training

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After 1990 Sanctions and 1991 War

• Declining salaries
• Informal imposition of fees
• Declining supply drugs, equipment
• Declining equipment maintenance
• Declining quality of care
• Increased emigration health professionals
• Emigration foreign health workers

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With Oil-For-Food Program 1996-2003

• Increased supply drugs, equipment
• No increased salaries
• No increase in training
• No increase in expenditure for recurring expenses
• Quality remained poor
• Emphasis remained on tertiary, specialist-based
  care

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With 2003 War, Occupation, Continued Violence

• Damaged and looted facilities
• Access restricted by violence
• Health outreach reduced
• But situation Baghdad and north improved since
  2003
• 2/3 health centers Baghdad rehabilitated
• Health centers rural areas and where violence
  continues not rehabilitated

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Al-Qaim May 2005
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Civilians Injured in Bombardment
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Angry Villagers
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Poor Quality of Services

• Chronic under funding
• Poor condition physical infrastructure
• Supply shortage
• Mismanagement
• Lack of staff
• Lack of modern skills and knowledge
• But MOH knows whats wrong - plans for
  improvements
• Recent pay raises

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Restricted Access

• Damage to facilities - inconsistent
• Continued violence
• Attacks by coalition forces, insurgents
• Brain drain from rural to urban
• Emigration
• Access for women, girls worse - fear sexual
  violence
• 20 Baghdad mothers unable to access maternal and
  child health services in last pregnancy, MOH

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Weak Management and Organization

• Since 1991 great decline health spending
• Creeping privatization, commercialization
• Poor distribution of resources
• Fragmentation of services
• Wide variability quality of care
• Weak referral system
• Onus on patients to access services
• Increasing self diagnosis and care
• Secondary care facilities crowded (costquality)
• Patients not turned away (income)
• Primary care poorly regarded (for the poor)

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Crumbling Facilities

• Hospitals, primary care centers destroyed,
  damaged, looted
• Public health labs destroyed, looted
• Vaccines lost
• 2/3 rehab hospitals Baghdad looted, closed
• Main psych hosp Baghdad looted, patients abused
  raped, turned loose
• 4/7 central supply warehouses looted
• Hospitals terrible condition garbage disposal,
  sewage disposal, water supply, power supply,
  shortage drugs equipment

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Workforce Problems

• Foreign workers left in 1990s
• Many Iraqi professionals left in 1990s
• Physician/population ratio low for region
• Nurse/physician ratio far below norm
• Relatives often provide nursing care in hospitals
• Poor in rural areas often served by staff with
  only rudimentary training
• Enormous need for training

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UNHCR officials just back from the region
reported that we now estimate there are at least
1.6 million Iraqis displaced internally, and up
to 1.8 million outside the country in neighboring
states. UNHCR spokesperson 11/3/06
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Doctors in Iraq
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Useful Sites

• http//www.psrla.org/
• http//www.psr.org/
• http//www.ippnw.org/
• http//www.medact.org/
• http//www.medpeace.org
• http//www.brookings.edu/fp/saban/iraq/index.pdf
• http//www.who.int/countries/irq/en/