Description

You could not write a scenario for a novel which had as many heroes as villains and then resulted in one central outcome, either a winning hero or a tragic death. For Iraq, politicians or forecasters will find it difficult to come through the current clouds with a clear blue sky – they may predict a free democratic and peaceful Iraq or alternatively chaos for years to come.

However, health planners are more optimistic than politicians, and in this issue of Public Health Medicine we are focusing on the future of health services in Iraq. Whilst we were very keen to give some predictions based on extensive experience of working with Iraq either directly or through international organisations, (in particular the World
Health Organisation), we still face considerable uncertainties, especially with the current security situation in the country.

Iraq is a wealthy country classified in the upper middle income rank of nations. Most of the national income comes from the huge oil reserve: the second largest in the world. Iraq is also rich in other resources: water, minerals, agriculture and well-educated workforce. The countrys stability and economy have been shattered by three wars
(the ten year war with Iran, the 1991 Gulf War following the invasion of Kuwait, and the 2003 American/British invasion/liberation of Iraq). To add to these tragedies, just in case they were not enough, Iraq has been subjected to two further evils: misgovernance since 1979, and the severe, punitive United Nations sanctions imposed on Iraq
in August 1990.

The tragic events of this sad story since then start to unfold. Most of the income from national resources was used to support the war efforts. Unemployment escalated. The brutalities of the regime and human rights abuses,¹ especially the crushing of any resistance or opposition to the regime,² are well documented. The excellent infrastructure of the country, including health,which was the envy of the region, were eroded, both by the punitive sanctions and neglect by the regime. The people of Iraq paid a heavy toll.³ The most vulnerable segments of the population paid with their lives: extremely high infant, childhood and maternal mortality rates beyond the imagination of
those who laid the foundations for a national health service in Iraq in the 1920s. Food became scarce and many families, especially those outside the cities, found it difficult to feed their children and cope with daily living. Malnutrition came to affect between 20% and 40% of the population, hitting children particularly hard.⁴ In the mid 90s, the UN
recognised the effects of the food shortages and proposed the infamous oil-for-food programme, which was mainly to support the food rationing system feeding 60% of the Iraqi population, as well as to provide medical supplies.⁵

The sudden interest of the international community in weapons of mass destruction (WMD), ignoring the fact that ordinary Iraqi citizens were struggling to survive, was a great surprise to many people inside and outside Iraq. To those people, the real WMDs are the punitive sanctions, the severity of which has never been experienced in the history of humanity. They were imposed by an organisation claiming to be the protector of peace, health and wealth of those living and sharing this globe: the UN.

The news of the liberation of Iraq and the demise of the brutal regime were welcomed inside and outside Iraq. Nevertheless, the sad story continues, if not worsens. Once again, misgovernment, lack of trust, absence of security, and diluted sovereignty are facts of daily life in Iraq, mainly due to the invading forces lack of preparation for the post-Saddam era. The populations health status and the system of health delivery is worse than they were before the invasion/liberation. In June this year the Ministry of
Health, for example, was unable to provide supplies of medicines for twenty chronic diseases and nearly half of the essential drugs on a list of nine-hundred had zero
stocks. Overcoming these and many other difficulties the health services are facing in Iraq, will require a clear vision on what type of health system Iraq should develop. Such a
vision needs to be translated into integrated strategic plans addressing all aspects of such a system – from enabling people to look after their health – to the highly specialised service delivery. Manpower planning is crucial especially after so many years of intellectual embargo.⁶

If one lesson can be learned from the sad story of Iraq, it must be to mistrust politicians. If one conclusion can be drawn, it must be never to place sanctions on any people
anywhere in the world. Punitive sanctions are the real WMDs and the consequences are well observed, documented in Iraq and hated by all of us.

References

1. Al-Shawaf T, Rawaf S. Human rights in Iraq. British Medical Journal 1995;
   310: 130.
2. Reis C, Ahmed AT, Amowitz L, et al; Physician participation in human
   right abuses in Southern Iraq. Journal of American Medical Association 2004;
   291: 1480-6.
3. United Nation and World Bank. Joint Iraq Needs Assessment. Geneva:
   World Health Organisation, 2003 (www.who.int accessed September
   2004)
4. World Food Programme. Baseline Food Security Analysis in Iraq. Rome:
   WFP, 2004.
5. Global Policy Forum. Iraq Sanctions: humanitarian implications and
   Options for the Future. New York: Global Policy Forum, 2002
   (www.globalpolicy.org see chapter 5).
6. Richards LJ, Wall SN. Iraq medical education under intellectual embargo.
   Lancet 2000; 355: 1093-4.