After two international wars (the Iran-Iraq war of 1980-88 and the Gulf war of 1991) and nine years of UN-imposed trade sanctions, the Iraqi economy lies in tatters. The "oil-for-food" programme, introduced by UN Resolution 986 in 1995, has not halted the collapse of the health system and the deterioration of water supplies, which together pose one of the gravest threats to the health and well-being of the civilian population. The situation is now exacerbated by water shortages owing to the worst drought in decades.
The Red Cross and Red Crescent Movement and other humanitarian organizations can only hope to mitigate some of the worst effects of the sanctions. In mid-1999 the International Committee of the Red Cross extended its budget for the year by 60% in order to fund new programmes in the field of health and water and sanitation, which are to continue in the year 2000 -- in full awareness of the fact that humanitarian aid can not nearly cover the overwhelming needs of 22 million people.
I. Nine years of sanctions
- Effect on the Iraqi Population
- 1. Health and nutrition
- 2. Collapse of the public health system
- 3. The water problem
- Oil-for-food -- chronology
- ICRC presence in Iraq
- 1. ICRC projects to help the wounded and sick
- 2. ICRC water and sanitation projects
- 1. Relief activities
- 2. A major programme since 1994 -- assistance for amputees
- 3. Prisoners or war and persons unaccounted for
- 4. Detainees
- 5. Activities specific to northern Iraq
Eight years of war with Iran (1980-88) followed by the Gulf war of 1990-1 left Iraq and the Iraqi people exhausted. The economy and, as a result, the infrastructure of the country lay in ruins. Now, after nine years of trade sanctions, imposed by the UN after Iraq's invasion of Kuwait in August 1990, the situation of the civilian population is increasingly desperate. Deteriorating living conditions, inflation, and low salaries make people's everyday lives a continuing struggle, while food shortages and the lack of medicines and clean drinking water threaten their very survival.
Added to this, in what has been called "the year's other war", United States and British aircraft have continued to bomb targets in the north and south of the country nearly every day since the four-day "Desert Fox" operation in December 1998, which followed Iraq's expulsion of United Nations weapons inspectors.
Effect on the Iraqi Population
As in war, it is civilians who are the prime victims of sanctions. Salaries are as low as US$2 a month; there is around 50% unemployment. People have had to sell their belongings in order to survive -- first their cars, then household appliances, even their books and furniture. Regular school attendance by children under 15 has fallen drastically since 1990 for "school does not give us money in order to live". And in the schools themselves, pupils often have to squat on the floor for want of chairs and desks. Water pipes have not been repaired, and there are huge pools of stagnating water in the school yard.
In the past
Just a decade ago, Iraq boasted one of the most modern infrastructures and highest standards of living in the Middle East. The world's second largest oil producer, it had in recent decades used oil revenues for ambitious projects and development programmes, as well as to build one of the most powerful armed forces in the Arab world. It had established a modern, complex health care system, with giant hospitals built on Western models and using the latest equipment. It had constructed sophisticated water-treatment and pumping facilities. It had an extensive school and university system. By 1990, therefore, Iraq presented some of the features typical of a modern society: reliance on imported food (about 70% of the calories in Iraq were imported in the 1980s), dependence on imported technology and engineering skills, and interdependence of the different branches of the economy -- accompanied by an attitude that "the government will do it for you" and "to replace is better than to repair".
No wonder, then, that Iraq's infrastructure should have proved so vulnerable to the effects of comprehensive trade sanctions, and with such devastating effect on the lives of civilians. The population, in particular doctors, technicians, and teachers, are now exposed to third-world problems which they had never been prepared to deal with.
Even if sanctions were lifted tomorrow, it would take years for the country to return to the same standards as before the Gulf war. Prospects for a better future are bleak, and an increasing number of Iraqis, especially the highly qualified, are trying to leave the country, or have already done so. This brain drain exacerbates the situation for those staying behind, as it leads to a loss of skills which are then not be passed on to the next generation.
II. Food, health and water
1. Health and nutrition
It is the weakest and most vulnerable who suffer from sanctions -- young children, pregnant women, the elderly, and people with chronic diseases.
According to a UN Children's Fund (UNICEF) survey published in August 1999 (Reference number CF/DOC/PR/1999/29),infant mortality in most of Iraq has more than doubled in the nine years since UN sanctions were imposed. In central and southern Iraq, home to 85 percent of the population, the death rate for children under five rose from 56 per 1,000 live births in the period 1984-9 to 131 per 1,000 in 1994-9.
The survey, which was prepared with the Iraqi government and the World Health Organization, did not specifically blame trade sanctions for the crisis which has seen some 500,000 Iraqi children die since the Gulf war. As for the autonomous Kurdish territory of northern Iraq, the survey found that deaths among children under five had dropped from 80 deaths per 1,000 live births in 1984-9 to 72 deaths per 1,000 live births between 1994 and 1999 (after having risen to 90 per 1,000 in 1990-4)(The UNICEF executive director who wrote the report attributed this discrepany to the large amount of international aid pumped into northern Iraq at the end of the war; in contrast humanitarian assistance began to reach central and southern Iraq only after April 1996, when Iraq agreed to the terms of the UN oil-for-food programme.).
For the first time in decades, diarrhoea has reappeared as the major killer of children. The highly specialized Iraqi doctors are now faced with third-world health problems -- malnutrition, diphtheria, cholera -- which they were not trained to handle.
According to UNICEF statistics from November
1997, a third of all children under five are chronically malnourished (UNICEF
statistics (Multiple Indicator Cluster Survey (MICS) carried out by Iraq's
Central Statistical Organization) from November 1997 showed that 32% of
Iraqi children under the age of five were chronically malnourished.). This
represents a 72% rise since 1991. Results from a nutritional survey of
15,000 children of the age of five, conducted by the Iraqi Ministry of
Health together with UNHCR and WFP in May 1998, show that the level of
malnutrition has stabilized since 1997, but that the situation is unlikely
to improve substantially unless water and sanitation and other sectors
receive larger financial input.
Given the gravity of the nutritional situation, in February 1999 the World Food Programme (WFP) launched a US$21 million appeal to help more than one million people in Iraq suffering from the effects of food shortages and poor water supply, including 200,000 acutely malnourished children (in particular the under-fives). These children have not had proper drinking water or sanitation since they were born.
2. Collapse of the public health system
Standards of care in hospitals and health centres have reached appalling levels, despite the doctors' dedication and high qualifications.
Iraq's 130 hospitals, many of them built by foreign companies in the 1960s-80s, have not received the necessary repairs or maintenance since the Gulf war, but above all since the imposition of sanctions. The buildings are in an advanced state of disrepair (cracked and leaking roofing, broken windows and doors, bulging floors), as are the hospital sewage works, the electricity and ventilation systems, the elevators. Expensive imported equipment, or even more basic items, are no longer being replaced.
Equally worrying is the state of the primary health centres, which serve the widest sector of the population. Public health in Iraq rests on the existence of over a thousand basic dispensaries covering the entire country and 84 intermediary health centres, which are in charge of coordination. The centres can not function properly owing to the shortage of equipment and material. They often lack the most basic tools such as stethoscopes, sterilizers and writing paper. The negative impact on the treatment received by patients, and hence on their health, is immense.
Standards of treatment are also falling as doctors can not keep their knowledge up to date. Hardly any medical literature has entered the country in the last ten years as the importation of scientific literature is prohibited under the embargo. During this time, Iraqi medical personnel has had few professional contacts with colleagues abroad. Psychiatrists, for example, have followed none of the developments of the last ten years in their field. Many young doctors and nurses have chosen to leave the country or to abandon the medical profession. As a result, standards of training have also fallen.
3. The water problem
Another major threat to the health of the population is the quality of the drinking water. The Gulf war severely damaged Iraq's infrastructure, interrupting the power supply and consequently the operation of pumping and treatment facilities. Since then, money and spare parts have not been available to repair sewage works and purification plants, which are often working at reduced capacity, or not at all. This has led to an overall deterioration in the quality and quantity of drinking water and the rapid spread of infectious diseases, such as cholera.
A UNICEF/government of Iraq survey in 1997 on the availability of water and sewage systems reported that more than half of the rural population did not have adequate access to clean drinking water, while for sewage disposal some 30% of the total population, predominantly in rural areas, were without adequate services. Much of the waste is discharged directly into rivers and streams, so that much of the water supplied is contaminated or below acceptable standards.
The low availability of power, averaging 50% in rural areas, frequent cuts and unstable supply place an additional strain on the installed electrical equipment. This, added to the fact that the chemicals used to purify the water contain around 30 times more impurities than before the embargo, leads to premature deterioration of the equipment, which subsequently requires more maintenance.
III. United Nations trade sanctions
The comprehensive trade embargo, which was imposed in August 1990 to incite Iraq to withdraw its troops from the recently-invaded Kuwait, has been renewed a number of times since then (After Iraq's invasion of Kuwait in August 1990, the Security Council imposed strict conditions on Iraq, demanding full disclosure, inspection and destruction of the country's biological, chemical, ballistic and nuclear weapon stockpiles and development programmes. Iraq was also ordered to pay reparations to Kuwait to compensate the victims of the invasion. The imposition of sanctions meant the suspension of customary trade and financial relations -- i.e. restrictions on the sale of Iraqi oil and the freezing of the country's assets. Meanwhile, Iraqi forces attempted to put down Kurdish and Shiite rebellions in the north and south. This led US and UK forces to impose two "no-fly" zones in the north and south. Despite attempts to have UN sanctions eased, the Security Council decided in 1993, and every year since, to maintain the economic embargo, because it concluded that Iraq had not fully complied with its obligations.). The Security Council has set up numerous mechanisms for exemptions from the sanctions regime, notably under UN Security Council resolutions 661 (1990), 687 (1991), 706 (1991), 712 (1991) and 986 (1995).
Resolution 986 (Oil-for-food) resolves some, but not all the problems
The most far-reaching of these humanitarian exemptions, resolution 986 (the "oil-for-food" programme) entered its fifth phase in March 1999. It has done much to alleviate the plight of the civilian population, especially as regards food and medicines. Malnutrition rates have stabilized since the programme began to be implemented in 1997. However, it has not halted the collapse of the health system and the deterioration of water supplies, which together pose one of the gravest threats to the health and well-being of the civilian population.
Resolution 986 also allows certain equipment to reach Iraq, for example pumps for water treatment. This does not, however, solve all the problems. The equipment needs to be properly installed and backed up by more general maintenance work on existing equipment and structures. The government often does not have the resources to pay for contractors to install it. This has thus become one of the major tasks for humanitarian organizations in Iraq.
Oil-for-food -- chronology
14 April 1995 Resolution 986 was adopted by the UN Security Council. Iraq subsequently refused to accept its terms.
10 December 96 The pumping of oil began under the Memorandum of Understanding (MoU). Phase I of the programme officially began.
20 March 97 The first shipment of commodities under Phase I was cleared.
2 April 97 The distribution of wheat flour began throughout the country.
9 May 97 The first medical supplies under Phase I arrived via Trebil (on the border with Jordan).
4 June 97 The Security Council adopted Resolution 1111 approving the 6-month extension of the operation and authorizing another US$2 billion in oil sales, beginning on 8 June.
8 June 97 Phase II of the programme began.
1 August 97 For the first time, Iraqis received all ten items in the monthly food basket at the levels envisaged in MoU.
October 97 The results of the FAO-WFP Special Report on Food Supply and Nutrition Assessment were published. The report found that, although the situation had improved following implementation of SCR 986, malnutrition remained a serious problem throughout Iraq.
November 97 A UNICEF report was published showing that 32% of Iraqi children under 5 were chronically malnourished, i.e. a rise of 72% since 1991.
4 December 97 The Security Council adopted Resolution 1143, formally extending the Oil-for-Food operation for another 6 months with the same ceiling of $US 2 billion in oil sales.
5 December 97 Phase III officially began.
20 January 98 The first medical contract under Phase II (vaccines for infants) was cleared at Trebil.
1 February 98 The UN Secretary General issued his Supplementary Report offering new proposals to improve the process for the approval of contracts and goods delivery. The report recommended enhancing the food basket with additional calories and animal proteins, and proposed that the ceiling of US$ 2 billion in oil sales every six months, which had proven inadequate to meet the needs of the Iraqi people, be raised to US$ 5.2 billion gross (US$3.4 billion for the humanitarian allocation).
20 February 98 The Security Council adopted Resolution 1153 in support of the Supplementary Report of the Secretary General.
19 March 98 The first shipment of food and related items under Phase III crossed the border at Trebil.
2 April 98 One year after the start of distribution of SCR 986 goods, nearly five million tonnes of foodstuffs had reached Iraq.
29 May 98 The Secretary General approved the Distribution Plan, based on a net humanitarian allocation of US 3.1 billion. This represented more than a doubling of the programme.
30 May 98 With Security Council Resolution 1153, the new and enhanced phase of Oil for Food operation began.
4 June 98 Results of a joint Ministry of Health-UN survey showed increased attendance at health-care centres and greater availability of drugs and medicines following implementation of SCR 986.
In 1999, the quantities of oil sold for the first time reached the level allowed under the programme ($5.26 billion/180 days under Phase VI). On 4 October 99, the Security Council increased the ceiling on the value of oil that Iraq is allowed to export by $3.04 billion for the 180-day period that began on 25 May. The estimated revenue for Phase VI is $7.464 billion.
IV. ICRC position in relation to the embargo
Active in Iraq since 1980, but particularly
since 1990, the International Committee of the Red Cross has been deeply
concerned to observe the consequences, in humanitarian terms, of the slow
but steady deterioration of living conditions in the country since the
1991 Gulf war. On several occasions the ICRC has drawn the attention of
the international community to this situation, in particular through regular
high-level contacts, in its emergency appeals and in its annual reports.
In October 1991, some 15 months after the adoption of Security Council Resolution 661 (1990) and the imposition of trade sanctions, the ICRC conducted a special mission to Iraq in order to assess the needs of the population and determine appropriate responses. The report on the findings of this mission was transmitted to the members of the Security Council in November 1991. The report stressed, among other things, that "Iraq's traditional reliance on imported food, the complexity of its public health system, the dependence of this system on imports and its interdependence with other sectors of the economy, together with the precarious state of the country's infrastructure as a whole, make Iraq particularly vulnerable to the effects of comprehensive trade sanctions". This observation has in large part proven to be true.
The ICRC recognizes that the humanitarian exemptions do indeed offer the civilian population some relief. Yet, it is convinced that exemptions, together with humanitarian action, although essential in order to address urgent and specific needs, can be considered only as partial, stopgap measures. As the ICRC stated in 1991, and reiterated in March 1999 in a "non-paper" transmitted to the UN panel set up to review humanitarian issues in Iraq, aid can be no substitute for a country's entire economy. It can never meet all the basic needs of 22 million people nor ensure the maintenance of a whole country's collapsing infrastructure.
ICRC PRESENCE IN IRAQ
The ICRC has slowly built up its presence in Iraq and consolidated relations with the Iraqi authorities over the last 19 years. During the first 10 years, the ICRC worked in accordance with its mandate under the Third Geneva Convention (visits to prisoners of war from the Iran-Iraq war and their repatriation at the end of the conflict). At the beginning of 1991, during the second Gulf war, the ICRC was the only international organization to remain in Baghdad, where it maintained regular contacts with the authorities in order to carry out its humanitarian tasks. Since then, the ICRC has developed its activities in Iraqi Kurdistan in full transparency with the Iraqi authorities and has been able to extend the scope of its different programmes all over the country, in response to the growing needs of the population.
Whereas in 1994 the organization had 12 expatriates and 92 local employees, in 1999 it has 34 expatriates (21 based in Baghdad and 13 in the north) and 265 local staff working in Iraq, with a total budget of US$ 14,286,425 (Sfr. 21,786,798). The ICRC's main office is in Baghdad, and there are three offices in northern Iraq (in Arbil, Dohuk, and Sulaymaniyah). It is thus the ICRC's largest operation in the Middle East.
V. Humanitarian response to the embargo
The ICRC endeavours to provide a rapid response to some of the needs which are not covered by the oil-for-food programme. In 1999, it extended its planned annual budget of US$9 million for Iraq by 60%, in order to finance new projects in two vital sectors: health, and water and sanitation. Meanwhile, other organizations are focusing their programmes on combating malnutrition within the Iraqi population. UNOHCI, the United Nations Humanitarian Coordination for Iraq, is the ad hoc agency coordinating implementation of SCR 986. All UN agencies, apart from UNHCR, are involved in their specific fields in supervising implementation of the oil for food programme, through small but regular programmes. A small number of NGOs is active in central Iraq, mainly in the primary health and education sectors. There are considerably more NGOs in northern Iraq, many of them implementing programmes under SCR 986.
1. ICRC projects to help the wounded and sick
After the air strikes of December 1998, the ICRC stepped up its support for medical facilities treating the war-wounded. This direct contact with Iraqi hospitals helped confirm the organization in its decision to conduct a comprehensive survey of the ailing Iraqi health system. From February to March 1999, the ICRC carried out an in-depth evaluation of the surgical facilities of 14 state hospitals, followed by a survey of primary health care facilities from April to June. This helped to identify the most pressing medical and surgical needs, on the basis of which a new medical programme for Iraq was drawn up.
In 1999-2000, the ICRC will:
- rehabilitate 11 hospitals in Iraq's main towns, paying particular attention to the surgical facilities. Repairs will be made to roofs, floors, windows, water supply and sewage systems, electricity, heating and cooling systems and elevators, in accordance with the needs of individual hospitals
- build a new sewage-treatment plant for four hospitals in Mossul
- provide surgical equipment and instruments for up to 18 major surgical hospitals throughout the country, as well as equipment for post-surgical care (theatre lights, surgical instruments, operating tables and autoclaves; blankets, sheets and surgical gloves)
- as part of a psychiatric programme: rehabilitate Iraq's main psychiatric hospital in Baghdad, provide literature on modern psychiatric treatment, train specialist psychiatrists on treatment protocols and diagnosis-determination methods, work with the hospital authorities to introduce occupational health therapy and provide the necessary equipment. Supply the necessary psychotropic drugs, anaesthetic drugs and medical material
- provide a selection of medical journals to every governorate, and textbooks and journals to the central library of the Ministry of Health.
In order to improve the quality of public health care, the ICRC will:
- carry out repairs on 26 primary health centres, including one in most governorates, giving priority to essential features such as water supply and sewage systems, electricity and major structural faults
- supply 20 or more primary health centres with basic equipment, including: stethoscopes, sphygmomanometers, thermometers, dental instruments, water filters and some furniture, according to each centre's needs
- in cooperation with the Ministry of Health, launch a pilot programme in the field of primary health care including: setting up health information systems, training staff in particular on data collection for these information systems and on the standard treatment protocol, supplying essential drugs and material and recent medical literature in Arabic
- provide assistance to Iraqi Red Crescent Community-Based First Aid training programmes.
PROFILE of four hospitals and one health centre
In the 400-bed Al Karama Teaching Hospital in Baghdad, which is fairly typical of Iraq's 18 large referral hospitals, according to the director "nothing works except the physicians". Situated in a very poor part of the city with high population growth, the hospital has all medical and surgical specialties, and is one of the largest teaching hospitals in Baghdad. Yet it is unable to function properly owing to a series of chronic problems.
The electrical system is erratic; the ventilation and elevators are out of order. The hospital sewage-treatment plant has not been working for years. In the wards lie rusty beds without wheels, with dirty mattresses with holes. There is a lack of soap, gauze, syringes, i.v. lines and fluids.
Only two of the hospital's six operating theatres are in use, and these are working on a very basic level. Lamp bulbs and trolleys are broken. The basic rules of hygiene and asepsis are not observed owing to a lack of detergents, disinfectants and water. The central oxygen supply is out of order, and few anaesthesia machines are working. There is a shortage of painkillers, especially those used for post-operative care.
Lifesaving procedures cannot always be performed owing to a lack of drugs, monitoring equipment or specific treatment. There are also few functioning diagnostic tools. As a result, the number of planned, non-emergency operations has greatly decreased. All this clearly has a disastrous effect on the quality of the treatment administered, and on the patients' health in general.
Basra Teaching Hospital. This is a major surgical teaching hospital with all subspecialities including orthopaedics, neurosurgery, chest surgery and ophthalmology. It not only serves the population of Basra (1.2 million) but is also the main surgical referral hospital for the entire southern part of the country (4 million). The director of the hospital tells of an incident during an operation when leakage from the toilet on the floor above dripped through the ceiling into the abdomen of his patient (the patient survived!).
Because of a design fault when the hospital was built in the 1980s, waste water seeps through the piping, out through the walls and ceilings. In the corridors, cracked and bulging floors reveal frequent flooding. The entire basement, in which service outlets, electricity cables, sewage systems, and pumping equipment are located, is completely inaccessible, inundated under a foot of flood water; stray dogs and rats have made it their home.
The director of Al-Rashad Psychiatric Hospital, the only hospital in the country for chronic psychotic p