"Health & Human Rights Consequences of War in Iraq" - A briefing paper

I. Executive Summary
The United States has spent many months planning for a concerted attack on Iraq, and in recent weeks, has revealed information about its massive military preparations. During this same period, there has been little public indication of plans and preparations to avoid civilian and "dual use" targets, minimize civilian casualties, or prepare for what may well be an enormous humanitarian crisis. Physicians for Human Rights (PHR) has concluded that preparing for such extraordinary use of military force to be deployed in a manner that will likely risk huge damage to infrastructure and civilian life, without due consideration for the consequences to the highly vulnerable population of Iraq, is intolerable.

When a power like the United States contemplates war, it must not only comply with the Geneva Conventions in the field that assure protection of the civilian and non-combatant population, but also engage in planning to avoid acts which are likely to harm the population. Under the terms of the Conventions, a warring party must adhere to the principle of proportionality and avoid fixing military targets in populated areas; it must refrain from attacking those systems that are vital to the health and welfare of the population; and it must assure food and medical supplies to the population once it becomes an occupying power. In the case of Iraq, issues like proportionality and mixed targets have enormous implications. Yet the US government has heretofore given little indication of taking this into account or assuring protection during and in immediate aftermath of military action.

Physicians for Human Rights (PHR) is gravely concerned about the potential for loss of life on a large scale and serious risk to the health and human rights of the Iraqi people and others in the region should a war take place. The combined effects of more than 12 years of economic sanctions, destruction of vital infrastructure, misrule by Saddam Hussein, and severe restrictions on civil and political liberties have left the Iraqi people extremely vulnerable in the event of war. Adverse affects of war on health and human rights that may result would not only manifest in the immediate aftermath of military intervention, but are likely to persist for a considerable period of time.

PHR joins in the call issued by other human rights organizations for the U.S. and its allies to be much more transparent about the anticipated consequences for the population during and following a war with Iraq and preparations for the anticipated humanitarian crisis.

Background to Assessment

PHR sponsored the travel of two health professionals to Iraq in January, 2003 to assess the health and human rights consequences of a possible United States-led military intervention in Iraq.

The PHR research team consisted of three experts in health and human rights. Two of the researchers, Charles Clements, M..D. and Ron Waldman, M.D. MPH, visited Iraq as researchers participating in a Center for Economic and Social Rights (CESR) delegation and conducted interviews in Baghdad, Kerbala, Kut, Basra, Tikrit, Beiji, Mosul, Kirkuk, and Amman, Jordan. A third PHR representative, Richard Garfield, R.N. traveled to Iraq independently during the same period of time and conducted interviews in Baghdad, building on his four previous visits to Iraq where he visited Erbil and Mosul, interviewed UN agencies and NGOs and took part in primary data collection.

The researchers collected information from Iraqi civilians, health personnel, government officials, and representatives of governmental and non-governmental humanitarian assistance organizations.

The researchers were able to access health clinics and hospitals, nutrition and food distribution sites, water treatment plants and electrical generation installations despite considerable logistic and political constraints. The assessment also utilizes existing data, including published and unpublished documents from academic sources and nongovernmental organizations. The researchers also had access to a number of unpublished United Nations documents. The analysis and interpretations contained in this brief report reflect PHR's independent assessment of information obtained in Iraq and through secondary sources.

Issues of Concern

PHR's assessment underscores the vulnerabilities of the population, including the following:

• Most of Iraq's 26 million people are almost entirely dependent for daily survival on the monthly rations distributed under the Oil-for-Food Program (OFFP). A disruption in the OFFP is likely to have extraordinary health consequences unless a comprehensive and effective food distribution plan is rapidly in place. In addition, war in Iraq is likely to disrupt supplies of other essential goods such as medicine, water and energy. In recent days, the UN has confirmed that OFFP personnel will be evacuated form Iraq should a war commence. In mid-February the UN emergency relief coordinator announced that the UN was ready to feed 250,000 people for 10 weeks. However, the anticipated need may be 40-times greater.
  
  
• The combination of a rapidly deteriorating health infrastructure, decline in access to public health and medical services, and a marked decline food availability to the Iraqi population for more than twelve years have contributed to a sustained deterioration of health status. During the past decade, infant mortality more than doubled to 107 deaths per 1000 live births per year, and the under-five mortality rate also more than doubled to 131/1000 live births per year.¹ War will compound the precarious nature of the health infrastructure and fragile health of the most vulnerable within the population.
  
  
• Preventative public health and curative medical services in Iraq are inadequate for the health and medical emergencies that are likely to result in the event of armed conflict. The number of primary health care (PHC) and maternal and child clinics, the principal providers of basic health care in Iraq, have declined by nearly half since the Gulf War in 1991 -- according to UNICEF, there are 929 PHC centers remaining out of a pre-Gulf War network of 1,800. Most of the health facilities are in poor physical condition. They often lack water and electricity and, hence, severely limit the quality of patient care.
  
  
• The water, sanitation, and electricity infrastructures in Iraq have not recovered from the previous war. This is in part due to sanctions, which have denied parts for much of the machinery used in these infrastructures as well as denial until recently of chemicals necessary for water treatment such as chlorine and aluminum sulfate. It is also clear that government of Iraq has not invested any significant resources in these sectors.
  
  
• Water treatment plants and sanitation facilities such as wastewater treatment and pumping stations operate at anywhere from 25 to 50% of design capacity. Capacity has been sacrificed due to cannibalization as well as steady deterioration that occurs when there is insufficient maintenance and no spare parts. UNICEF and the United Nations Development Program report that 40% of water samples fail tests either for contamination by solids or sufficient disinfection.
  
  
• Water treatment, water distribution, sewer treatment, and sewer pumping are all highly dependent upon electricity in the largely urbanized country (70% of the population lives in cities). While these systems have back-up generators, they are designed for short-term power failures, have insufficient capacity to operate for long periods of time, and are themselves slowly becoming dysfunctional. Today 50% of the sewage in Baghdad's largest treatment plant is shunted directly into a river and estimates are that 500,000 tons of raw sewage enter waterways daily in Iraq.
  
  
• The electrical generating and distribution system is only marginally functional. Electrical black-outs due to insufficient power availability range from 6 to 14 hours per day in many cities. As observed by the PHR investigators, the electrical system is held together with 'bailing wire' as it has been deemed dual use and spare parts delayed for years or denied.
  
  
• According to UNICEF, some water borne diseases such as typhoid are now seen at incidences of 1000% compared to pre-Gulf War levels. Vulnerable sectors such as malnourished children, pregnant women, and the elderly will be immediately susceptible to epidemics of water borne diseases if the electricity system is paralyzed and water/sanitation systems cease to function.
  
  
• The current state of humanitarian preparedness is cause for great concern. Very few international agencies with large-scale emergency capacity are currently present in Iraq. Thus, far, the U.S. government's public statements on how it intends to conduct military actions in Iraq have not included sufficient information and/or support for humanitarian relief efforts for Iraqi civilians who are likely to be directly and indirectly affected by such actions. As of February 14, 2003, the U.N. stated that it has fewer than half of the resources it needs to cope with the anticipated humanitarian crisis.
  
  
• Internally Displaced Persons (IDPs) and refugees in Iraq and on its borders are at great risk. Turkey and Iran have already threatened to close their borders. Under such circumstances, IDPs will not be able to cross international borders to safety and will remain vulnerable to the effects of military actions, basic life-sustaining supplies and/or possible reprisal attacks by Iraqi forces. [XX] Many humanitarian organizations urge that preparations be made to accommodate larger numbers, perhaps as high as several million refugees.
  
  
• An attack on Iraq may unleash violent reprisals by the Government of Iraq against internal opponents, including the Kurds in the North and Shiite Muslims in the South, but also against perceived political opponents as well as military deserters.
  
  
• Antipersonnel mines may be used by both sides in this conflict and threaten to harm non-combatants. Similarly, cluster bombs in Iraq would, in all likelihood, maim and kill far more innocent civilians than soldiers, especially if they are used against Republican Guard forces, which are municipally based.
  
  
• Reports of the torture and ill-treatment of captured combatants in Afghanistan by both the United and its ally, the Northern Alliance, have created cause for serious concern. In the event of a war with Iraq, captured, surrendered, and wounded Iraqi military forces are entitled to Prisoner of War status in accordance with the Geneva Conventions and their rights must be protected.

Recommendations

To Prevent War

In the interest of protecting human life and health, PHR appeals to the U.S. Government the United Nations and the Government of Iraq to exert every effort to resolve the conflict with Iraq without a resort to military force.

To Protect Civilians and Non-Combatants in the Event of War

In the event that war occurs, concerted steps should be taken to assure that human rights and humanitarian law are respected. PHR calls upon the US Government and its allies to comply with their obligations under the Geneva Conventions, which is their duty at a minimum, and to take measures to protect civilians that, in some cases, exceed the strict requirements of international humanitarian law.

The U.S. Government must take crucial steps to protect the civilian population and captured combatants through strict compliance with international humanitarian law, including the Geneva Conventions. This includes scrupulously avoiding civilian targets, respecting the principles of proportionality, providing for the nutritional and health needs of the people of Iraq and others who may be affected by the conflict, protecting Iraqi citizens against reprisals by their own government, caring for refugees and displaced persons.

• The President should issue a military mission statement that ensures strict adherence to humanitarian law by the United States combatants and take responsibility for assuring compliance by local allies, assets and agents. The Pentagon must promulgate rules of engagement to carry it out.
  
  
• Weapons should be deployed in such a way that civilian casualties are avoided to the maximum extent possible. The U.S. should seek to avoid military operations in heavily populated areas, regardless of the military legitimacy of the targets, if large numbers of civilians could be harmed. The U.S. and its allies should eschew targets that are essential to civilian survival such as water supply, electricity, food storage facilities, and hospitals, even if some of this infrastructure has dual military-civilian use.
  
  
• The U.S. should have in place prior to going to war capacity to deliver basic humanitarian services to all in need, from the minute the war commences throughout the period of upheaval, including food, shelter, water, and access to health care. Declassified versions of US preparations should be made transparent to all humanitarian groups servicing the region.
  
  
• The United Nations appealed in mid-February 2003 for over $100 million for humanitarian contingencies, of which $60 million is allotted to United Nations High Commissioner for Refugees. The remaining funds are to be distributed to other intergovernmental organizations, including the International Organization for Migration. The United States has to date given approximately $25 million to the UN for contingencies for humanitarian needs. The U.S. should ensure that the UN receives the full amount it needs before commencing a war. The U.S. should assure adequate food, water, medical supplies and shelter for Iraqis, both those in their homes and villages who are dependent on the oil-for-food program, and those who flee their homes as displaced people within Iraq or refugees in neighboring countries. A similar plan should be instituted to ensure constant supply and stock of essential medicines. The Government of Iraq must also assure passage of humanitarian supplies and enable assistance to be distributed in a neutral manner as required by the Geneva Conventions.
  
  
• The U.S. Government should immediately suspend the requirement that humanitarian groups and others must have OFAC licenses2 to operate in Iraq and Iran. This will allow American groups to hire local staff, preposition supplies, and prepare for the massive numbers of people that are expected to flee hostilities. The U.S. Government must also facilitate the mobilization of international and American assistance in Iraq at every point before, during and after the war.
  
  
• The U.S. and allies must prepare for and develop a plan to prevent or stop reprisals by Saddam Hussein against Iraqi citizens in the midst of a conflict. This should include prevention of and preparedness for the burning of Iraqi oil fields and other elements of a scorched earth policy, as well as a chemical or biological attack against the Iraqi people, in addition to those in neighboring countries.
  
  
• The U.S. should not deploy antipersonnel landmines whose inherent indiscriminateness will otherwise cost many civilian casualties and should not use cluster bombs in populated areas. The U.S. and its allies should also make the demining of the Iran-Iraq border a priority if hostilities commence, in order to minimize civilian losses as refugees flee into the area, or minimally, to provide safe movement corridors.
  
  
• The U.S. and U.N. must gain, through diplomacy, assurances from Iraq's neighbors that they will fulfill their obligation of nonrefoulement as stated in the 1951 Refugee Convention and keep their borders open to those fleeing the war. The US should also provide required resources to UNHCR to address a large refugee influx on Iraq's borders.
  
  
• The U.S. and the U.N. must ensure that proper security arrangements are in place to control post-war aggressors and facilitate the establishment of a stable society operating under the rule of law with respect for human rights of all inhabitants of a post war Iraq.
  
  
• The U.S. military should set in place a system for reporting and investigating violations of the laws of war that are committed by U.S. personnel as well as their local allies, agents, and operatives in Iraq. They must establish means of accountability for such abuses.
  
  
• PHR insists that the U.S. Government and its allies take full responsibility to ensure that prisoners of war be treated according to the Third Geneva Convention.3 In the event of a war with Iraq, captured, surrendered, and wounded Iraqi military forces are entitled to Prisoner of War status in accordance with the Geneva Conventions. The U.S. must also ensure that its local allies and agents who may have authority over wounded or surrendered combatants treat them in accordance with Geneva standards. Failure to do so in the war in Afghanistan resulted in U.S.-backed Afghan forces reportedly allowing hundreds of surrendered Taliban combatants to die under their watch.4 All conflicts provide opportunities for violations of laws of war by combatants. The US government and its allies must develop a system for reporting and investigation of the laws of war that are committed by US personnel, their local allies, agents and operatives in Iraq. The US government must also establish means of accountability for such abuses.
  
  
• Abuses perpetrated by any party to a conflict must be addressed. In recent decades, accountability mechanisms have been developed to tackle violations of human rights and humanitarian law during conflict. These include international tribunals such as those created in the aftermath of the conflicts in Rwanda, the Former Yugoslavia and most recently, Sierra Leone and the establishment of an International Criminal Court. The international community must demand accountability for violations of the laws of war by all parties to the conflict. The US and its allies must not stand in the way of such efforts.

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Notes:

¹ The Situation of Children in Iraq: An Assessment Based on the United Nations Convention on the Rights of the Child " UNICEF, February 2002 available .