The Human Costs of War in Iraq

Originally published


The Center for Economic and Social Rights (CESR), based in New York, is a non-partisan international organization dedicated to promoting social justice through human rights. CESR has consultative status with the United Nations Economic and Social Council and serves as the T Secretariat for the International Network on Economic, Social, and Cultural Rights, with hundreds of member organizations throughout the world.
Since 1991 CESR staff have organized six humanitarian missions to Iraq. These include the Harvard Study Team in March 1991, which first documented the post-war public health crisis and had its humanitarian findings incorporated into Security Council records; the International Study Team in August 1991, which conducted the first epidemiological study of child mortality in post-war Iraq; and a legal mission in 1996, which criticized Security Council sanctions policy for human rights violations and was featured on 60 Minutes. CESR's innovative reports have consistently highlighted the human costs and international law implications of war and sanctions in Iraq, and demanded that all parties to the conflict, including the international community as a whole, respect the human rights of the Iraqi population irrespective of the conduct of their leadership.

In response to the current crisis, CESR is working with concerned civic groups and individuals on an Emergency Campaign on Iraq. The purpose of the Campaign is to ensure respect for humanitarian and human rights principles by all parties to the Iraq conflict. Main activities include: sending fact-finding missions to Iraq; preparing a range of educational resources, from legal and scientific reports to popular fact-sheets; and advocating for a peaceful, law-based resolution to the crisis.


This report is dedicated to the 24 million Iraqi civilianswho have lived through 12 years of hardship and face the prospect of yet another war.

We are grateful to all the Iraqis, United Nations personnel, and international aid workers who consented to be interviewed and shared documents with us for this report. We are also grateful to our Jordanian translators - Rajaa Al Jazar, Zakaria Salameh, Ali Abu Shakra, and Luay Shalkoub - who often translated under difficult conditions.

We would like to thank Terry Allen for the layout of the report in Baghdad. Special thanks to Hans von Sponeck, Ramzi Kysia, Sarah Leah Whitson, Ayliz Baskin, Jacob Park, Jason Florio, Robert Huber, Chris Caruso, Sara van der Pas, and Brenda Coughlin.

The six mission participants conducted research and wrote the first draft of the report under demanding conditions in Iraq. Elisabeth Benjamin, with Ronald Waldman, was responsible for the overall editing of the draft report in Baghdad. The following team members had primary responsibility for each of the sections: Health ~ Michael VanRooyen, Ronald Waldman, Elisabeth Benjamin; Food and Nutrition ~ Peter Pellett and Elisabeth Benjamin; Electrical Infrastructure ~ Michael McCally; Water and Sanitation ~ Charlie Clements; and Humanitarian Preparedness ~ Ronald Waldman.

The Executive Summary was written by Roger Normand with Sarah Zaidi. The final report was produced and edited by Sarah Zaidi, Roger Normand, Elisabeth Benjamin, Hadi Ghaemi, and Jacob Park.

CESR gratefully acknowledges the generous financial support of The Ford Foundation, the Mertz Gilmore Foundation, and the John D. and Catherine T. MacArthur Foundation.

The views expressed in this report are those of the Center for Economic and Social Rights and do not necessarily represent the views of individual contributors.


Executive Summary
Chapter 1: Introduction
Chapter 2: Methodology
Chapter 3: Health Care System
Chapter 4: Food and Nutrition Status
Chapter 5: Infrastructure
Chapter 6: Humanitarian Preparedness in the Event of War
Appendix A: The 1991 Gulf War and A Possible War Scenario
Appendix B: Principles Guiding Humanitarian Action
Appendix C: United Nations Confidential Document Analysis
Research Team Biographies
Executive Summary

The Center for Economic and Social Rights (CESR) sent a team of experts to Iraq from January 17-30, 2003 to establish a baseline of current conditions and assess the probable T consequences of war. The Research Team's main finding is that the international community is unprepared for the humanitarian disaster of another war in Iraq.

The CESR Research Team was comprised of six experts in food security and nutrition, public health infrastructure, primary and public health care, and emergency and curative medicine. The Research Team: 1) conducted interviews in Baghdad, Kerbala, Kut, Basrah, Faw, Tikrit, Beiji, Mosul, Kirkuk, and Amman, Jordan; 2) collected extensive data from Iraqi civilians, clinic and hospital staff, government and United Nations (U.N.) officials, and staff of non-governmental organizations (NGOs); and 3) conducted a thorough literature review.

In addition, the Research Team obtained confidential U.N. documents on humanitarian conditions and emergency planning and conducted a review of available literature.1

The Research Team was afforded an unusual level of independence by the Government of Iraq. Most interviews and visits were conducted without Iraqi "minders" and with independent bilingual translators from Jordan.

This report focuses exclusively on the humanitarian implications of war to encourage informed public discussion and effective international action on this crucial yet overlooked element of the Iraq crisis. This limited focus does not reflect acceptance that war against Iraq is either justified or inevitable. While team members hold diverse political opinions about the war, they all agree that the human costs of war are unacceptably high.

The Research Team deplores the rush to war by the governments of the United States (U.S.) and the United Kingdom (U.K.) and urges that all possible steps be taken to achieve peace in accordance with fundamental principles of the United Nations Charter. The Research Team also deplores that Iraqis live under a repressive government that abuses human rights and contributes to the current vulnerabilities of the population. The people of Iraq should not be forced once again to pay the price for the political impasse between their leadership, the U.S. government, and other states.


No one can precisely predict the extent of the crisis.2This report makes an informed assessment of probable humanitarian consequences of war based on field research, secondary data, confidential U.N. documents on humanitarian planning, and analysis of precedents. The main findings of the report are summarized below.

1. The Iraqi population is far more vulnerable to the shocks of war than it was in 1991, having been reduced after 12 years of sanctions to a state of dependency on government and international aid. Previously, Iraq was classified as a rapidly developing country with a modern urban infrastructure, an extensive welfare system, and a thriving middle class with significant personal assets.3 After 12 years of sanctions, the population has been impoverished and the civilian infrastructure remains fragile. Many characteristics of Iraqi society today are more comparable to the circumstances found in long-term refugee settings than to those in developing countries.

  • Since 1991, Iraq's rank on the United Nations Human Development Index has fallen from 96 to 127. No other country has fallen so far, so fast.4 Over 60% of the population - 16 million people - depend for survival on a comprehensive government food rationing system.5 The ration is purchased through the sale of Iraqi oil and supplied through funds controlled and administered by the Oil-for-Food Program (OFFP).6

  • The OFFP limits economic opportunities by failing to implement a cash component; civil servant salaries averaging US$3-6 per month cannot cover even subsistence needs.7

  • While nutritional status has improved recently due to increased humanitarian supplies under the OFFP and two years of good harvests, any disruption to the food distribution or health care systems will cause a rapid setback.

  • Iraqis have been extremely isolated from the outside world for 12 years; the mental, physical, and educational development of an entire generation has been adversely affected by the extraordinary trauma of war and sanctions.8
2. International agencies are not adequately prepared to respond to the humanitarian consequences of war, especially if civilian infrastructure is attacked or disabled. Military attacks against electricity, transportation, telecommunications, and other necessities of modern civilian life would cause the immediate collapse of Iraq's water purification, sanitation, public health, and food distribution systems, leading to increased hunger, sickness, and death, especially among children. Similar attacks in the 1991 war contributed to 47,000 excess child deaths within eight months.9

The CESR Research Team observed that few physicians or nurses have the necessary training to care for traumatic injuries. During war it is almost certain that the emergency health system would be overwhelmed. Given current vulnerabilities, civilian casualties could be far greater than in 1991, especially in the event of an extended military conflict with a siege of Baghdad.10

A confidential U.N. document warns that "the collapse of essential services in Iraq could lead to a humanitarian emergency of proportions well beyond the capacity of U.N. agencies and other aid organizations."11 The document also reports that:

  • "In event of a crisis, 30 percent of children under five [approximately one million children] would be at risk of death from malnutrition."

  • "Military conflict would result in significant disruptions of critical infrastructure in South and Center of the country . . . and sizeable internal and external population movements." UNHCR is preparing for 600,000 refugees.

  • "Access to war-affected civilians would be severely limited for the duration of the conflict."

  • "The capacity of the Government and other assistance providers to deliver basic services and to conduct relief operations would be severely limited."

  • "UNICEF expects shortage of essential drugs, especially antibiotics, to occur within one month of the onset of crisis."

  • Although agencies have engaged "in a discreet planning and preparedness effort for several months... [t]he current response capacity of the United Nations system remains well below the critical requirement established through the inter-agency planning process."
3. Any attempts to replace rather than supplement Iraqi public health, food distribution, and infrastructure will exacerbate the humanitarian crisis. While Iraqi systems are severely stressed, they are functional and the majority of the population relies on them. The Research Team was struck by the dedication of thousands of professional staff and civil servants who maintain these crucial survival systems despite extraordinary obstacles. The U.N. acknowledges that the "humanitarian needs of the Iraqi population as a whole can be met only by national and local authorities" in light of "high levels of existing vulnerability and the dependence of most of the population on [the Government of Iraq] for their basic needs."12 The most common international approach to humanitarian emergencies is to establish new or parallel structures to provide food and medical treatment, as in a refugee camp. But this approach would deprive war-affected Iraqis of billions of dollars in humanitarian supplies provided by the OFFP as well as the services of thousands of experienced professionals.
  • Iraq has 929 primary health care centers, compared to 1,800 prior to 1990. The Ministry of Health operates several hospitals in each governorate, partially financed by user fees, with a total capacity of 27,000 beds.13

  • Iraq's food distribution system, the largest such operation in world history, supplies 24 million people with approximately 2,470 kilocalories per day through a network of 46,000 rations agents in the South and Center of Iraq. Despite its massive scope, this system serves to mitigate, rather than end, deprivation associated with sanctions.14

  • Iraq's electricity system has an installed capacity of 9,500 megawatts to power its modern infrastructure. Although there is a partnership between Iraq, NGOs, and the UNDP to rehabilitate the system through the OFFP, current capacity remains at 43% of installed capacity.15
The national output of potable water remains at 50% of previous capacity and water quality remains substandard.16 Through repairs and rationing, access to safe water is approaching 1990 levels: 94% urban and 45.7% rural coverage.17

4. The secrecy of humanitarian preparations by the United States and the United Nations is impeding efforts to develop an effective emergency response capacity. The United States has not shared information about humanitarian planning with international agencies that are planning to provide assistance inside Iraq. Such secrecy regarding relief operations is difficult to reconcile with the U.S. government's detailed public statements about military operations. Similarly, U.N. agencies have also prepared confidential documents on emergency planning for Iraq that they have not shared with other relief agencies. Under these circumstances, the right of affected populations to receive assistance is likely to be compromised.

  • The U.N. has closely guarded its operational planning for emergency relief, making effective humanitarian coordination with international NGOs difficult.

  • The U.S. Department of Defense has prepared a classified humanitarian proposal that has been shared with members of Congress but not with the members of the international relief community.18

  • A consortium of American NGOs has received grants of almost US$2 million from USAID for relief aid in Iraq, yet relatively few have received necessary government licenses to operate in Iraq or neighboring countries. These groups have complained publicly about the lack of coordination between various government departments=A1=AAthe Pentagon, State Department, USAID Office of Foreign Disaster Assistance, and Treasury Department OFAC.19
5. All parties to war are obligated to respect the well-established principles governing humanitarian action: humanity, neutrality, independence, impartiality, and accountability. Under this framework, there is a clear separation between humanitarian actions and the political, military, or economic actions carried out by governments during a conflict. Military operations need to be distinct from humanitarian activities, especially at the height of hostilities. Civilians should not associate humanitarian organizations with military objectives.
  • In off-the-record interviews, NGO staff expressed widely shared concerns that funding and access are being politicized to favor those humanitarian organizations most sympathetic to the war aims of the U.S. government.

  • International relief agencies, especially in Europe, have publicly criticized the U.S. for politicizing aid and failing to guarantee humanitarian access to post-war Iraq as a right protected under international law.20

  • The tactic of airdropping individual food rations, condemned by the U.N. and independent relief agencies in Afghanistan as an ineffective and dangerous conflation of military and humanitarian operations, will apparently be conducted on a much greater scale in Iraq.21

  • The subordination of humanitarian to military goals undermines principles of humanitarian action, neutrality in particular, and risks exposing aid workers to military attack and civilian anger, as happened in Afghanistan.

In the event of war, 30 percent [more than one million] children under five are at risk of dying from malnutrition. - U.N. Contingency Plan

The Iraqi people already suffer severe deprivation under sanctions and will be in much greater need of humanitarian assistance in the event of another war. The total amount of grants pledged by governments (US$65 million from the United States and US$15 million the United Kingdom) is a tiny fraction of the revenues from Iraqi oil sales under the OFFP. For Phase XIII (December 5, 2002 to June 3, 2003), the Sanctions Committee has already approved more than $1 billion of humanitarian supplies (food, medicine, vaccines, and spare parts) out of an expected total of $4.93 billion in oil sales revenue.22

The Office of the Iraq Program has stated that the OFFP would be terminated in the event of war, and that the $10.9 billion worth of supplies already in the pipeline =A8C paid for by Iraq but not yet delivered =A8C would not be released without a new Security Council resolution.23 It is safe to predict that the humanitarian crisis resulting from another war in Iraq would far exceed the capacity of U.N. and international relief agencies. It is thereforeessential that the Security Council, and the U.S. in particular, respond to a number of urgent questions:

Are civilian life support systems, in particular electricity, water, and sanitation, considered military targets as in the 1991 war?

What are the contingency plans to prevent repetition of the "cycle of death" caused by increased malnutrition and disease, especially among children?

What will happen to Iraqi government food distribution and public health systems in areas occupied by U.S. and other military forces?

What will happen to the food, medicine, and other humanitarian supplies currently provided through the OFFP Program?

How will the international community mobilize the enormous aid package necessary to prevent or mitigate a disaster?

Why are humanitarian response plans being developed in secrecy and without necessary coordination among key actors?

Will the U.S. military allow international relief agencies independent access to affected populations as required by humanitarian principles and international law?

The humanitarian community, and the international public in general, deserve answers to these life and death issues from the Security Council, and the governments of the U. S. and the U. K. in particular, in order to make informed decisions about the crisis in Iraq. With the world poised on the brink of a potentially catastrophic war, this does not seem too much to ask.


1 United Nations Executive Committee for Peace and Security, "Portrait of Iraq," Strictly Confidential (January 7, 2003); United Nations, "Portrait of the Current Socio-Economic Development Situation and Implications in Iraq Based on Specified Scenarios," Confidential (January 20, 2003) [hereinafter "U.N. Portrait"]; United Nations Office for the Coordination of Humanitarian Affairs, "Integrated Humanitarian Contingency Plan for Iraq and Neighboring Countries," Confidential Draft (January 7, 2003) [hereinafter "U.N. Contingency Plan"].

2 This report does not base different humanitarian outcomes on specific military scenarios. A number of other studies do that. See, e.g. Rogers, P., "Iraq: Consequences of a War," Oxford Research Group (October 2002); MedAct, "Collateral Damage: The Health and Environmental Costs of War on Iraq," IPPNW (November 2002); U.S. Military Displaced Civilian (DC) Camp Operations (November 11, 2002).

3 Economist Intelligence Unit Report (1996).

4 UNDP, Human Development Report, (July 2002).

5 United Nations, "Likely Humanitarian Report Scenarios," (December 10, 2002).

6 U.N. Portrait.

7 UNICEF, "The Situation of Children in Iraq," (February 2002) [hereinafter UNICEF Iraq Report]. Because of the lack of implementation of the cash component GOI cannot use OFFP revenue to pay local salaries or make purchases other than what is approved by the Sanctions Committee.

8 U.N. Portrait.

9 Ascherio, A., Chase, R., Cote, T. et al., "Effect of the Gulf War on Infant and Child Mortality in Iraq," New England Journal of Medicine, 327: 931-36 (1992).

10 Rogers, Paul, "Iraq: Consequences of a War," Oxford Research Group (October 2002); MedAct, "Collateral Damage: the Health and Environmental Costs of War on Iraq," (November 2002).

11 U.N. Contingency Plan.

12 U.N. Contingency Plan.

13 UNICEF Iraq Report.

14 Gazdar, Haris, "Pre-Modern, Modern and Postmodern Famine in Iraq," Institute of Development Studies Bulletin, (October 2002).

15 UNDP, "Sectoral Report" (2003).

16 UNICEF, "Water and Sanitation Briefing Iraq South/Centre," annexed to "Working with Children to Build a Better Future," (undated 2002).

17 UNICEF Iraq Report.

18 CESR interviews in Washington, D.C.

19 Grossman, Elaine, "Humanitarian Crisis in Iraq Could Fast Undercut War Aims," Inside the Pentagon (February 6, 2003); CESR Interviews in Washington, D.C. and in Amman, Jordan (February 2003).

20 Save the Children, et al, "Joint NGO Statement Against War" (Sept. 23, 2002).

21 Schmitt E. and Shanker, T. "U.S. Military Set to Provide Aid to Iraqi People in the Event of War," NY Times (February 11, 2003).

22 U.N. Office of the Iraq Programme. "Plan for Phase XIII" (January 3, 2003); Office of the Iraq Programme, "The Humanitarian Programme in Iraq Pursuant to Security Council Resolution 986 (1995): "Note by the Office of the Iraq Programme," United Nations (November 12, 2002). Over the past six years, the government of Iraq through the Oil-for-Food Program has provided revenue for current humanitarian activities and United Nations administration. Between December 1996 and October 31, 2002, the Sanctions Committee has approved humanitarian supplies valued at $42 billion, including $3.7 billion for the oil sector. Of this amount, $26 billion worth of goods have been delivered, including $1.6 billion worth of oil industry spare parts and equipment. This is equivalent to an average $685 per person per year in the Center/South. Approximately $10.9 billion worth of humanitarian supplies are currently in OFFP delivery pipeline.

23 United Nations Office of the Iraq Programme, Update 25-31 January, 2003.

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