Blood and Sand

I have written on occasion about public health in occupied Iraq, but today I'm going to do my best to give an overview of what we know, and in particular what we don't know. Specific, credible numbers are unavailable because Iraq does not have a functioning public health system. We lack meaningful disease surveillance, vital statistics, or health care utilization data. The World Health Organization does not offer any recent information on population health in Iraq, and the Iraqi Ministry of Health, as far as I have been able to determine, does not produce any systematic public information. The UN Development Program conducted a survey of Iraq's infrastructure in 2004, which included an assessment of health care facilities, but for unstated reasons the report has been taken down.

Iraq's people were suffering prior to the invasion and occupation, after decades of misrule, war, and international sanctions. Indeed, this was a principal justification that many liberal hawks gave for supporting the war -- that it was the only way to quickly end the sanctions regime, and provide for the welfare of the Iraqi people. Sadly, as the third anniversary of the invasion approaches, all indications are that public health in Iraq has only deteriorated.

Recently the individual who is most culpable for the tragedy conceded that approximately 30,000 Iraqi civilians have died as a result of the war. He was apparently referring to the figures compiled by Iraq Body Count, an organization which counts deaths documented in news reports and other publicly available sources. Obviously, this method captures only traumatic, mostly violent deaths directly attributable to the wartime situation, and is far from a complete count even so. Even in the extraordinarily violent environment of Iraq today, however, most deaths are from other causes. The first question is how the overall death rate may have changed since the beginning of the war. (Of course, deaths are not the only indicator of population health.)

In the absence of a functioning vital records system, researchers from U.S. universities and Al-Mustansiriya University in Baghdad conducted a survey in September, 2004, based on area probability sampling methods, to estimate how the death rate in Iraq changed from the 14.6 month period before the war started in May 2003, to the 17.8 month period following. They estimated that the mortality rate had nearly tripled, and that 100,000 excess deaths of civilians had occurred up until that date. Although the corporate media insist that we should not believe this result, it is in fact based on sound methods and is about the best we can do under the circumstances. (Actually, this is undoubtedly an underestimate. The investigators deliberately excluded the city of Fallujah so as not to "skew" the results.)

At about the same time, the British organization Medact issued a report drawing attention to devastated sanitary infrastructure, rising malnutrition and damage to hospitals and public health laboratories, and declaring a public health crisis in Iraq. Earlier, in May 2003 shortly after the invasion, UNICEF conducted a rapid assessment of children's nutritional status in Iraq and found that acute child malnutrition had nearly doubled since before the war, from 4% to 7.7%. Acute malnutrition is a very serious condition that leads to permanent developmental deficits. Prior to the war, UNICEF was able to refer malnourished children to a network of Nutritional Rehabilitation Centers, but this system collapsed with the invasion. I have not found any information that it has been re-established.

Again in October 2004 -- which seems to have represented a window period for information -- the Iraq Ministry of Health issued a report which, according to the summary in Nature, stated that:

Disruption to water supplies during the conflict means that roughly 20% of urban households now have no access to safe drinking water. This has led to 5,460 cases of typhoid in the first quarter of 2004, the report estimates. In rural areas, more than half of households are without fresh water or adequate sanitation.

More Iraqis may have died as a result of ... neglect of the health sector over the past 15 years than from wars and violence. Measles and mumps are infecting thousands of children, partly because a third of them are chronically malnourished, it is reported. There were 8,253 cases of measles reported in the first half of 2004, with Basra particularly badly hit. In 2003, there were just 454 cases. Likewise, the first four months of 2004 saw 11,821 cases of mumps, nearly 5,000 more cases than there were in the whole of the previous year.

It is now more than a year later, and the only up-to-date information available is anecdotal. The intrepid Dahr Jamail reports that in the region of most active combat, particularly al-Anbar province, U.S. forces continue to raid, disrupt and damage hospitals in pursuit of insurgents. Even without the attacks, hospitals are barely functioning due to lack of electricity, non-functioning equipment, shortages of drugs and supplies, and curfews which force personnel to go home and services to stop after 5:00 pm.

Jamail also reports that unemployment is approximately 70%, most Iraqis cannot afford to feed themselves adequately, and hospitals in general are barely functional.

Nearly three years after the invasion, the U.S. can no longer legitimately blame Saddam Hussein for conditions in the country. Yet the administration has announced that it does not intend to spend any additional funds on the reconstruction of the country. Trends since September 2004 have undoubtedly been negative, so it is reasonable to suppose that excess deaths since the invasion are now at least somewhere close to 200,000 and probably mroe. But the future burden of a malnourished, chronically infected, psychologically traumatized population without access to medical care will continue to devastate the country for decades, regardless of how soon stability can be established and economic and social conditions improve.