Health and welfare in Iraq after the Gulf crisis - An in-depth assessment
The Team consisted of eighty-seven researchers drawn from a wide variety of disciplines, including agriculture, electrical engineering, environmental sciences, medicine, economics, child psychology, sociology, and public health.
Team members visited Iraq's thirty largest cities in all eighteen Governorates, including rural areas in every part of the country. The mission was accomplished without Iraqi government interference or supervision. Principal funding was supplied by UNICEF, the MacArthur Foundation, the John Merck Fund, and Oxfam-UK.
The study team has prepared separate in-depth reports on the Gulf Crisis and its impact on Iraqi civilians focused on the following subjects:
1. Child Mortality and Nutrition Survey
2. Health Facilities Survey
3. Electrical Facilities Survey
4. Water and Wastewater Systems Survey
5. Environmental and Agricultural Survey
6. Income and Economic Survey
7. Child Psychology Survey
8. Women Survey
This statement summarizes the principal findings of the research. Individual project reports, representing the findings and views of individual authors, are available for more detailed information.
The economic and social disruption and destruction caused by the Gulf Crisis has had a direct impact on the health conditions of the children in Iraq. Iraq desperately needs not only food and medicine, but also spare parts to repair basic infrastructure in electrical power generation, water purification, and sewage treatment. Unless Iraq quickly obtains food, medicine, and spare parts, millions of Iraqis will continue to experience malnutrition and disease. Children by the tens of thousands will remain in jeopardy. Thousands will die.
CHILD MORTALITY AND NUTRITION SURVEY
Infant and child mortality and nutrition were assessed by conducting surveys in 9,034 households in every region of Iraq. The households were chosen on the basis of stratified random sampling techniques. The household survey was conducted by a team of 32 mostly female Arabic-speakers under the supervision of 10 public health specialists.
Within each household, mothers were questioned about the number of children born, the date of birth, whether the children were still alive, and, if deceased, the date of death. This is the standard method for obtaining accurate data on infant and child mortality.
Based on these interviews, it is estimated that the mortality rate of children under five years of age is 380 per cent greater today than before the onset of the Gulf Crisis (see Table One).
The practice of public health specialists is to state infant and child mortality as a proportion of live births. Before the Gulf Crisis, the mortality rate for children under five years of age was 27.8 deaths per thousand live births. Since the Gulf Crisis, the under-five mortality rate has increased to 104.4 deaths per thousand live births (see Figure One).
Furthermore, it is estimated that the mortality rate of children under one year of age (the infant mortality rate) is 350 per cent greater than before the onset of the Gulf Crisis (see Table Two).
During January to August 1990, before the Gulf Crisis, the infant mortality rate was 22.7 deaths per thousand live births. Since the Gulf Crisis, the infant mortality rate has increased to 80.0 deaths per thousand live births (see Figure Two).
The rise in infant and under-five mortality is likely due to a complex interaction of factors. There are acute shortages of food and essential medicines throughout Iraq. Lack of clean drinking water and poor sanitation have greatly increased water-borne diseases, such as cholera, typhoid, dysentery, and gastroenteritis.
A random sample of 2,902 children registered during the course of the household survey were also measured for their height and weight. These figures were combined with the children's ages in order to estimate the incidence of malnutrition among infants and children in Iraq. Nutritional status was assessed by looking at three different criteria: 1) Height for Age; 2) Weight for Age; and 3) Weight for Height. According to internationally accepted practice, children were classified as malnourished if they fell two or more standard deviations below the median reference values of the World Health Organization (see Chart Three).
Nearly 29 per cent of the children assessed were malnourished under one or more of these criteria. According to the World Health Organization, there are a total of 3.3 million children under five years of age in Iraq. Applying the 29 per cent figure to this total number leads us to estimate that over 900,000 Iraqi children are malnourished.
The third criterion used to assess child malnutrition, weight for height, is a measure of severe food deprivation or deficient utilization. In a layperson's terms, a child who falls two or more standard deviations below the median value for weight for height is moderately or severely malnourished, with a significantly increased risk of dying. About 3.6 per cent of Iraqi children assessed were malnourished under this criterion (see Table Three). Applying this 3.6 per cent figure to Iraq's total population of children under five leads us to estimate that 118,000 children are either moderately or severely malnourished and therefore at increased risk of dying.
The incidence of severe malnutrition appears greatest among children between one and two years of age (see Figure Three). For example, 5.3 per cent of these children measure two standard deviations or more below the median value for weight for height and therefore, are considered moderately or severely malnourished and at extreme risk. Moreover, over one-third of children of this age are malnourished according to one or more of the three criteria.
HEALTH FACILITY SURVEY
The study team included five health professionals (three medical doctors and two public health specialists), who visited 29 hospitals and 17 community health centers located in nearly all governorates of Iraq. At each hospital, they conducted ward prevalence studies of admitted patients, interviewed facility directors, department heads, and physicians, and analyzed medical and hospital records of malnutrition and disease. The ward-based analysis concentrated on patients under the age of five.
Mortality for patients under five years of age varied dramatically throughout the country. For example, at Babel Pediatric Hospital, it has increased 3.9 times for the first seven months of 1991 while at Diwaniya, an increase of 1.2 fold was documented. The incidence of diseases was similarly uneven. With the improvement of Baghdad's water supply the risk of communicable diseases in Baghdad has substantially diminished in recent months, while in southern Iraq the morbidity pattern is substantially more acute and remains at epidemic or near-epidemic levels.
Within hospitals, infant and child malnutrition is clearly the most significant problem documented by the health facility team. Among in-patients at Erbil Pediatric Hospital, the prevalence of malnutrition, as an admitting diagnosis, was 71 per cent; at Sulaymaniyah, 66 per cent; at Mosul, 66 per cent; and at Ramadi Pediatric Hospital, 61 per cent. Food shortages and frequent gastroenteritis appear to have contributed to a very high level of malnutrition. This is reflected in the large increase in low birth weight babies. As an example, in Kut, low birth weight babies represent 30 -- 50 per cent of all live births compared to 12 -- 14 per cent in 1990. The cost of infant formula on the open market has increased 2,000 -- 3,000 per cent since August 1990.
In addition, water-borne diseases, including typhoid, gastroenteritis, and cholera are epidemic. Hepatitis has increased throughout Iraq and by as much as one hundred-fold in some areas. Meningitis is now widespread in southern Iraq. With the damage to child vaccination programs, such preventable diseases as measles and polio are also resurgent.
Strained health facilities operate at only a fraction of pre-crisis levels. Most lack even basic medical supplies such as vaccines, antibiotics, anesthetics and syringes.
Medicines are in extremely short supply. As a result, infectious diseases go untreated. There is little or no chloramphenicol for typhoid, fluids for rehydration of those suffering from cholera or gastroenteritis, or antibiotics for meningitis. Lack of vaccines and poor sanitary conditions have resulted in outbreaks or previously uncommon and preventable childhood disease, such as polio, measles, and tetanus.
Drugs for chronic diseases are also unavailable. The rate of coronary attacks has increased substantially because patients with heart disease are unable to obtain anti-angina medication. Teenage diabetics are dying because they cannot obtain insulin. Children with treatable leukemia are dying because anti-cancer drugs are largely non-existent. Laboratories, X-ray units, neonatal units, and operating theaters either do not function or provide only limited services.
Due to lack of water and detergent, sanitation was poor in nearly every hospital visited. The supply of water to most hospitals and health centers is sporadic. In a bacteriological survey conducted in southern Iraq, 30 per cent of hospital water sources were grossly polluted with coliform indicating fecal contamination. In Kurdish areas, tested water supplies of hospitals found heavy coliform pollution. Moreover, the water that is supplied is often contaminated with fecal matter. Lavatories are clogged. At several hospitals, raw sewage had backed up into the wards.
ELECTRICAL FACILITY SURVEY
The project surveyed the conditions of most major electrical facilities in Iraq. The sites were selected by team members to gain a comprehensive picture of conditions throughout the country. The study was comprised of site inspections and interviews at 24 facilities over a ten day period.
During the Gulf Crisis, enormous damage was inflicted upon the electrical generation infrastructure of Iraq. Since the cease fire, electrical generation has been restored to about 68 per cent of the 1990 peak load (5,162 MW) but, to only 37 per cent of the installed capacity (35 MW). The study estimates 75 per cent of electrical transmission lines are operable. All repairs have neen done using salvaged parts and improvised methods.
Much of this repair, especially in the switchyards and first-span connections to transmission, does not meet normal standards of construction, poses increased safety risks, and is likely to break down. Without spare parts, replacement and further repair will not be possible. The store of salvageable parts is depleted. Iraq does not have the capability to manufacture the necessary items. Many are specific to the foreign companies form Europe, Japan, and North America that built or supplied all the power stations.
Finally, the study team documented the profoundly negative impact that the damaged and ill-repaired power generation system has had on, and will continue to have on, water purification and wastewater treatment and public health infrastructure generally.
WATER AND WASTEWATER SYSTEMS SURVEY
Civil and chemical engineers, inspected water and wastewater treatment plants, distribution systems, and collection systems in all parts of Iraq. Twenty-eight facilities including eighteen water treatment plants, eight wastewater treatment plants, one water supply and one aluminum sulfate plant were visited in thirteen cities.
Much of Iraq's water and water purification facilities function at only a fraction of pre-Gulf Crisis levels or not at all. Only one of eighteen water treatment plants inspected operated at 100 per cent capacity. Water distribution and purification suffer from minimal flow and lack of chlorine which is being rationed at all plants. The primary factors impairing water treatment and purification do not result from damage caused by the war and civil uprisings; but from a lack of spare parts and chlorine. Wastewater treatment, water delivery and purification are also substantially limited by the lack of electrical power.
Reduced water flows and insufficient levels of chlorine in the distribution system promote the incidence of water-borne diseases. The lack of electrical power has eliminated wastewater treatment in Baghdad and southern Iraq and raw sewage is being discharged into waterways. Sewage treatment is also dramatically reduced because of a lack of chlorine, spare parts and reliable electrical power. The study team estimates that if current trends continue, the entire water treatment and delivery system will deteriorate to the point of collapse. Within a matter of months, those critical public services are expected to be operating at only 5 -- 10 per cent capacity.
ENVIRONMENT AND AGRICULTURAL SURVEY
Environmental and chemical engineers investigated and interviewed public health officials, environmental regulators and local residents concerning the environmental and public health consequences of the Gulf Crisis.
Team members collected drinking water samples at 158 randomly selected households in all 18 governorates in Iraq. The sampling framework of the public health survey team was used to collect drinking water samples.
Most of Iraq's population of 18 million is directly exposed to water-borne disease in their potable water supply. Each sample was tested for coliform or fecal contamination. The results were 106 positive for gross coliform contamination, 25 confirmed negative, and 27 unconfirmed negative. Roughly half the areas tested, weighted according to population density, showed positive evidence of gross fecal contamination. Only in Baghdad, where coliform media sampling was used, did over half the samples test negative. Team members documented unsanitary water source and waste disposal conditions in all cities surveyed. Common conditions observed included: (1) solid waste accumulating in the streets due to the lack of collection and landfilling equipment, (2) raw sewage overflows in the streets and around homes, (3) raw sewage being dumped directly into the rivers due to impaired or inoperable wastewater treatment plants, (4) children bathing and playing in these rivers, (5) people with little to no tap water supply because impaired or inoperable water treatment and distribution plants cannot generate adequate line pressure, (6) people drawing drinking water directly form the rivers, and (7) people drawing drinking water from holes dug in watermains, which are often contaminated by cross-connections from adjacent sewage pipes.
The team found that direct sewage contamination of water supplies results from two primary causes: inadequate chlorinating of discharges or bypassing treatment entirely; and contamination through breaks in the watermains.
Over 60 per cent of the population in five of the seven governorates surveyed no longer have tap water available in their homes because of low water supply system pressure. The low pressure is caused by lack of spare parts to maintain pumps, power outages, and breaks in the water mains.
INCOME AND ECONOMIC SURVEY
Two economist members of the team studied the impact of the Gulf Crisis on economic activity, private incomes, public distribution and household consumption.
More than a year of war and internal conflicts have had a disastrous impact on the economy. The destruction of the economic infrastructure and an acute shortage of imported inputs have caused a considerable decline of output and wage employment (especially in the private sector). The reduction of formal employment opportunities, and the general impoverishment of the population, have led to a large-scale expansion of "informal" self-employment (e.g. street-vending).
Overall, money earnings have remained more or less unchanged for the majority of the population since August 1990. Over the same period, consumer prices have sharply increased, due to trade restriction, exchange-rate depreciation and reductions in subsidies. The food price index has risen by 1,500 to 2,000 percent.
Correspondingly, real earnings have fallen to less than 7 per cent of their pre-crisis level, in terms of purchasing power over food. In terms of private incomes, the incidence of poverty is now greater in Iraq than in, say, India. The collapse of private incomes has been further aggravated by the deterioration of many basic public services.
These adverse development have been partly compensated by the expansion of public food distribution. Iraq's public distribution system, which covers all residents (except in areas not currently administered by the government, particularly the north), is equitable and efficient. However, food distribution covers at best one half of the nutritional needs of the population. Many households have to sell their assets to complement food rations with market purchases.
The paralysis of economic activity and basic public services, inadequately compensated by food rationing, has been one of the major causes of nutritional depravation and enhanced mortality.
CHILD PSYCHOLOGY SURVEY
On the basis of in-depth interviews of 214 Iraqi children of primary school age, two professional child psychologists report levels of anxiety, stress, and pathological behavior unprecedented in their fifteen year experience in this field. For example, nearly two-thirds of children interviewed believe that they will not survive to become adults. Nearly eighty percent are afraid of losing her/his family through death or separation. Eighty percent experienced shelling at close distance. The researchers conclude that "the high proportion of affected children clearly calls for a substantial national and international response to provide the necessary technical, professional, and educational means ... to held these affected children."
A report on the state of women was compiled by three researchers who conducted in-depth interviews with eighty Iraqi women. The collapsed Iraq economy has driven many families to poverty. Due to the sanctions and the damaged water and electricity infrastructure, as well as, fuel and food shortages, eighty per cent of women interviewed described a situation where the burden of their domestic responsibilities had increased significantly. Fifty seven per cent of the women reported suffering from health problems. The Iraqi people, especially the women, are overwhelmed by their daily struggle to provide for their children even the most basic needs of food and water. Many women are forced to sell their jewelry, and other household assets to raise money to buy food for their children. The crisis is worst in the case of vulnerable groups, such as widows, who do not have any personal assets to sell for food and other basic necessities.
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