IPPNW European Student CongressNapoli May 2006

Enduring effects of war: health in Iraq Photo: Doctors for Iraq

“We have opened the Pandora’s box and the question is what is the way forward?” US ambassador to Baghdad Los Angeles Times 7 March 2006

81% of households lack proper sanitation 68% lack access to potable waterSpecial Inspector General for Iraq Reconstruction January 2006

“Doctors fear to be attacked by the occupying forces and…many times cannot attend…due to road blocks and curfews…”medical student Ramadi Iraq Communique Summer 2005

Medact

UK charity for global health highlights the health impact of violent

conflict, poverty and environmental degradation

membership organisation of health professionals

UK affiliate of International Physicians for the Prevention of Nuclear War (IPPNW)

Medact: work on conflict and health

health costs of 1990-1991 Gulf War psycho-social work in former Yugoslavia improving refugee health in the UK seminars on reconstruction of health system in

Afghanistan impact on health of war on Iraq:

reports 2002; 2003; 2004

updates July 2005; March 2006

Medact: work on conflict and health

2004 Report:

enduring effects of war:

health in Iraq 2004

www.medact.org

Medact reports on Iraq: why?

to stimulate debate on health effects of war to hold government to account to assess the adequacy of reconstruction efforts to use health data to help prevent war

Medact reports on Iraq: how?

desk studies interviews with a range of people working in Iraq 2004 report: visits to Amman wide dissemination through IPPNW affiliates and

media

Medact reports on Iraq: how?

multi-skilled research teams panel of expert advisors funding from Oxfam (GB), Lionel Penrose Trust and

Polden-Puckham Charitable Foundation

Medact reports on Iraq: how?

Role of students and doctors 2002 Iraq report: research by Catherine Ford and Robert

Henderson, medical students on international health course 2003 Iraq report: researcher and author Dr Sabya Farooq,

epidemiology and public health masters graduate 2004 Iraq report: researcher and editor Dr Trishan Panch

physician, international health consultant 2004 Iraq update: researched and written by Tom Yates,

medical student 2005 Iraq update: researched and written by Kingston Reif, US

international relations graduate; MSc intern in UK

Medact reports on Iraq: constraints

inadequate baseline data lack of information denial of information war and aftermath

Situation before war on Iraq 2003

1990-91 Gulf War; sanctions; Saddam Hussein’sregime dramatic “break” in health improvement after 1990 decline in functioning of health system decline of health-sustaining infrastructure increase in poverty increase in corruption

health of population very vulnerable to new war

collateral damage: the health and environmental costs of war on Iraq Medact 2002

Overall picture since 2003 war

Casualties of war and aftermathCombatant: Iraqi Deaths: 13,500-45,000 estimate

Injuries: 40,500-135,000 generally calculated x3 number of deaths

Combatant: coalition Deaths: 2,428 (US); 109 (UK) 111 (other) Injuries: 17,869 (US) Iraq Coalition Casualty Count 10 May

2006

Combatant injuries

Iraqi combatants: no information available

Coalition combatantsUS: survival rate 90% (WWII 70%, Vietnam 76%) 6% required amputations 20% have suffered head and neck injuries at least 1,700 brain injuries: estimated long term cost of treatment

$14 billion

UK: 230 injured: 12 required amputations January 2006

30-40 have suffered paralysing injury, loss of eye or brain damage January 2006

Casualties of war and aftermath

Iraqi civilian deaths

98,000 excess deaths estimated from nationwide cluster sample survey September 2004. Roberts et al. 2004

39,258 reported maximum Iraq Body Count 10 May 2006

Average violent deaths per day rising: Iraq Body Count 20 March 2006

Year 1 post-combat 20 per dayYear 2 post-combat 31 per dayYear 3 post-combat 36 per day

“30,000 more or less” Iraqi civilians dead President George Bush

The Washington Post December 12 2005

Iraqi civilian deaths

Photo: Doctors for Iraq

Weapons used by coalition in combat

cluster weapons: unexploded bomblets causing child deaths and injuries

depleted uranium: general health risks unclear; cancer risk from inhaled particles

napalm bombs; white phosphorus

Geneva Convention Protocol 1 prohibits indiscriminate attacks, use of indiscriminate weaponsespecially in built up areas; prescribes protection of civilians

question of legality of use of these contentious weapons

Cluster bomb injury

Photo: Doctors for Iraq

Decline in health of population

rise in deaths from all causes since invasion substantial increase x58 in risk of death from violence high child mortality; 50% children malnourished high maternal mortality; reported rise in back street

abortion vaccine preventable disease preventable child deaths from diarrhoeal disease,

acute respiratory infection: 70% child deaths in 2004 rise in mental health and social problems

Living amidst conflict

crisis of law and order: insecurity and fear insurgency & sectarian violence; threat of civil war crime; kidnappings detention of 15,000 Iraqis by US + allies March 2006;

12,000 by Iraqi authorities November 2006 torture and killings

Living amidst conflict

women and girls threatened: rape; human trafficking education severely disrupted surges in internally displaced people health and aid workers targeted

Mental health

Civilians impact of estimated 50% unemployment increase in anxiety and mood disturbance longer term: expected increase in suicides, drug and

alcohol abuse, social and domestic violence almost no mental health services increased behavioral and learning problems in

children and adolescents

Mental health

“The only things they [Iraqi children] have on theirminds are guns, bullets, death and a fear of the USoccupation” Association of Psychologists of Iraq, February 2006

children suffer fear of kidnapping and explosions 92% found to have related learning impediments

report of Association of Psychologists of Iraq, 5 February 2006

Mental health

Photo: Doctors for Iraq

Mental health

Combatants up to 1/3 returning US troops suffer mental health

problems (estimated 40,000) or marriage problems returning US soldiers: higher incidence of post

traumatic stress disorder than in Vietnam or first Gulf war

by January 2004 21 US troops were reported to have committed suicide

Health sustaining infrastructure

reconstruction faltering: funding falling; corruption; 25% - 50% of funds spent on security

water and sanitation facilities damaged and looted power network extensively damaged and looted water and electricity key for nutrition and functioning

of health system: supply well below pre-war level majority depend on food baskets under Public

Distribution System

Health sustaining infrastructure

Photo: Doctors for Iraq

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Health system

all activities to promote, restore or maintain healthWHO

Health system

“Imagine yourself trying to operate on a patient in a two-

hour surgery and the power goes out… You pray toGod, and you sweat” Dr Waleed George, May 30, 2005

Health system

Photo: Doctors for Iraq

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Health system

destruction; looting; 90% hospitals needed repair or reconstruction March 2005

large increase in funding but still low: $38 per capita in 2004

corruption; medical supplies diverted increase in pay for health workers: but low relative to

rising cost of living overwhelmed by surges in violence the system struggles to function…

Health system

lack of basic supplies: patients purchase drugs & supplies from black market

widespread commercialisation: twice as many Iraqis use private services than public services

constitution pro-privatisation lack of capacity of Iraqi Ministry of Health lack of coherent Iraqi health policy inequities in distribution of health facilities

Health system

doctors & health workers attacked, shot at, threatened & told to leave or die

2,000 physicians murdered since 2003 estimate

65 doctors killed in 2005 250 physicians kidnapped since invasion estimate

34,000 registered physicians before invasion; 12,000 have left since due to security situation

medical care and access to medical care impeded by military operations

breaching of medical neutrality

Baghdad medical teaching

facility

Photo: Doctors for Iraq

Relief and reconstruction

no plan pre-invasion for health reconstruction UN marginalised then bombed confused relationship between military and

humanitarian actors Coalition Provisional Authority did little: a lot of money

was spent but much unaccounted for only 30% of Madrid Conference pledges received hampered by violence

Reconstruction

“We were never intending to rebuild Iraq…. Wewere providing enough funds to jump-start thereconstruction effort in this country.”Gen. William H. McCoy commander US Army Corps of Engineers, January 15 2006

emphasis on reconstruction of hospitals and clinics rather than how they would function

£1.1 billion profits made by British construction and security firms

USAID cancelled contract with US healthcare company because of incompetence

Conclusions

death and injury of tens of thousands of Iraqi civilians and

combatants numbers rising 2003 war exacerbated damage to health of Iraqis

from previous wars, former regime, and sanctions immediate impact of conflict on health represents a small

proportion of the longer term suffering security crisis; collapse of state; continuing

violence; threat of civil war health system in crisis with rising demands; poor

progress in reconstruction; health workers targeted; skills drain

Medact: key recommendations

Independent inquiry an independent commission should make a thorough

investigation of casualties and the state of health in Iraq since the invasion in 2003

Count the Casualties Campaign 2005

www.countthecasualties.org.uk

Medact: key recommendations

Protecting health in conflict

require occupying forces to: comply with the Geneva Conventions monitor casualties and civilian protection re-evaluate the impact of weaponry in populated

areas ensure health services are accessible to civilians in

conflict areas and the protection of health workers

Medact: key recommendations

Longer term interventions

to improve health and build peace: strengthen stewardship role, capacity and funding of

Iraqi Ministry of Health to rebuild an Iraqi health system based on primary health care principles moving away from charges at the point of delivery to fully tax-based system

role of health system in nation building and building peace

Further work

by Medact monitoring of health in Iraq: update on Iraq health

situation Communiqué March 2006 proposal for 2006 report on health in Iraq development of an advocacy programme, using health

impact of violent conflict in prevention of war, and upholding of rule of law

www.medact.org

Further work

by other organisations Iraq Body Count press release on civilian casualties

9 March 2006 Crisis Action: Medact collaboration on health risks of

potential attack on Iran IPPNW appeal to Kofi Annan to set up a mediation

commission on Iran

www.iraqbodycount.netwww.crisisaction.org.uk

Postscript: "what one person can change"

NGOs working in conflict and health :opportunities for students, young doctors, public healthspecialists as volunteers or in project work analysis authorship editing testimony advocacy campaigning

www.medact.org