Health trends in Iraq with a focus on children: No cause for optimism

By Debarati Guha-Sapir and Frederick M. Burkle Jr
2 June 2014 (Journal of Tropical Pediatrics) – With the 2003 invasion of Iraq by the USA and Coalition Forces, U.S. Defense Secretary Rumsfeld assured the removal of military forces within 60 days and, despite pleas from within and outside his own circle of advisors, rejected the possibility of any humanitarian or public health crisis [1]. What resulted became a country torn apart by sectarian violence, a shattered health system and an ongoing public health emergency defined primarily by preventable mortality and morbidity. A decade later, it is time to take stock of the impact the war has had on its most vulnerable population, the children. In the 1980s, Iraq enjoyed a health care system of well-equipped hospitals, highly trained medical specialists and a comprehensive system of primary care clinics. In preparation for the impending 1991 war, the health budget was cut by 90%. Health conditions deteriorated, especially in the south where malnutrition and water-borne diseases were common, and the salaries of medical personnel decreased drastically. Adding insult to injury, the 2003 invasion destroyed 12% of hospitals and public health laboratories, and nearly two-third of its qualified medical personnel emigrated [2]. Today, it is difficult to reliably comment on the health status, as vital registration and health data requirements are not being met or are difficult to obtain. Notwithstanding the progress made by World Health Organization in improving population registrations and national surveillance, insights are possible through very few specialized health studies. Key indicator data of child health are fragmentary but provide a cautious, although alarming, view into health trends. What is known is that there is a steady increase in child mortality since the invasion [3]. In terms of child mortality data ratings in eight countries, Iraq slipped from a rank of 5 in 1990 to the bottom of the list by 2011. With continued civil violence and dysfunctional public health services the proportion of children with full immunization coverage dropped from 80% in 1990 to barely over 40% in 2011, well below 83–94% herd immunity levels, the worst of the region [4]. Routine maternal and newborn health services have declined without clear evidence of recovery. Ministry of Health (MOH) surveillance data confirmed a measles vaccine failure rate of 66.1%, with greater risk in Governorates where the war was fiercest [5]. United Nations Children’s Emergency Fund (UNICEF) analyses from 2000 to 2011 indicate a fifth of newborns exposed to the war failed to receive neonatal polio immunization [6]. The current polio outbreak in Syria places Iraq at particular risk. Although health budget cuts and global sanctions were blamed for the worsening malnutrition rates in the late 1990s, nation-wide surveys in 2011 have not shown improvement, leaving nearly a quarter of the children aged less than 5 years stunted. Hospital sanitary conditions are also an increasing concern. In two Tikrit hospitals, a third of children were diagnosed with nosocomial diarrhea directly linked to unsanitary practices by the medical staff, contaminated bed linens, food containers and unopened cans of infant formula [7]. Broader concerns include the etiology for the increased rates of cancer, especially those living in areas of intense combat operations. Significantly high rates of congenital abnormalities are found in Fallujah as well as a doubling of childhood leukemia rates in Basra, a possible link to the use of depleted or enriched uranium ammunition [8, 9]. Children with newly diagnosed cancer suffer ‘shortcomings in provision of health services including professional manpower, infrastructure, diagnostic and therapeutic facilities, and supportive and palliative care’ [10]. Civilians, especially children, continue to bear the brunt of war-related injuries. Evidence from combat support hospitals in Afghanistan and Iraq indicate that nearly half of the injured civilians were children, primarily injured by gunshots and explosives [11]. The overwhelming expatriation of qualified primary and pediatric specialty care physicians and nurses have considerably weakened the health system. Nearly a quarter of the physicians and 60% of specialists left the country by 2007 [12]. Rebuilding this expert pool is a major challenge requiring specific policies for the short and long term. While Iraq has made some progress in the past decade, it has been unable to make up lost ground. The majority of the child deaths since the invasion are due to failed or dysfunctional public health protections rather than outright violence [12]. [more]