Summary

Evidence that child mortality is on the rise

The purchasing power, the food situation and the living conditions of the majority of the population have all deteriorated. Half of the active population has no job and no income. The prices of basic necessities, food and transportation have doubled or tripled. The quality of the drinking water is not being controlled, the sewage system of Baghdad has been damaged by the bombings, there is no regular garbage collection. Iraq has become one big garbage belt. All these indicators put together point towards a rising child mortality, a fact being acknowledged by the WHO representative for Iraq. It also brings Unicef to the conclusion that child mortality will probably increase further.

Medical infrastructure and medicines: no improvement

The medical infrastructure and the medical material were already outdated and malfunctioning as a result of the twelve years' embargo. One year after the onset of the war, these have not yet been renewed. War victims and other patients do not receive optimal treatment. Complicated operations cannot be performed. Everything is lacking, including medicines for acute as well as chronic ailments. This results in deteriorating conditions or even the death of patients, and in extra handicaps for the wounded. On March 17, right after the explosion at the Mount Lebanon Hotel in Baghdad, we helped care for victims in the Ibn Al Nafis hospital. We observed there that there were no disposable gloves, no appropriate intravenous fluid to treat shock, to ultrasound, no well-functioning monitors,…

Findings

1. Testifying about the situation in the hospitals is made difficult.
2. The purchasing power, the food situation and the living conditions have deteriorated. An increase in child mortality is to be expected.
3. Insecurity creates psychological traumas.
4. Access to health care is severely limited.
5. The hospital infrastructure has not improved over the past year.
6. Medicines and medical material are lacking.
7. Depleted Uranium (DU): the population is not informed nor protected.
8. The plans of the CPA and the Ministry of Health are no solution.
9. Appendix: April 2004: US-led troops in Iraq are targeting hospitals, ambulances and civilians.

1. Testifying about the situation in the hospitals is made difficult.

Access to hospitals is very limited, the press is hardly allowed to enter. It was only with difficulty and through personal contacts with medical doctors that we could enter several hospitals. Doctors who dare to testify before the camera are intimidated and put under pressure. We talked to two doctors who had given an interview. Afterwards, someone from the Ministry of Health visited them. They were forced to sign a letter stating that they wouldn't give any interviews anymore, or else that they would lose their job in the hospital.

2. The purchasing power, the food situation and the living conditions have deteriorated. An increase in child mortality is to be expected.

According to the CPA (Coalition Provisional Authority, the US administration led by Paul Bremer), 35% of the active population is jobless. Other sources speak of 60 to 70%.
During the embargo, several foodstuffs were distributed for free among the population; it concerns dry goods such as rice, tea, beans, sugar, wheat, milk powder, oil, salt and things such as washing powder and soap. This distribution is being continued, but regularly some goods are lacking. E.g. in March, there was no rice. As a consequence, everybody was forced to buy rice on the free market, which pushed prices up. And anyhow, the food that is not contained in the food basket - vegetables, fruits, meat, fish, cheese, eggs,… - has to be bought on the market. Their prices have increased two- or threefold over the past year.
The majority of the population has less cash available, while the cost of living has increased. The purchasing power has diminished, access to food is less assured. Many families depend entirely on the food basket. Unicef notes that malnutrition today is higher than after the first Gulf War of 1991, and the number of children with acute malnutrition rose sharply in the first months after the onset of the 2003 war.

The provision of electricity in Baghdad has deteriorated. Water services are still in worse condition than before the war, and nobody knows the quality of the drinking water. In some places there is still no water coming out of the faucet.
The sewage system was already in precarious condition before the war. It has been hit by the bombings and hasn't been repaired ever since. In many poor quarters of Baghdad, dirty water is standing in the streets. Garbage collection is not yet well organized. Garbage is all around the place.

The three main factors that influence child mortality (under five mortality) at the level of the family are the purchasing power, the food situation and the living conditions. All three of them have deteriorated over the past year in Iraq. The local Unicef representative confirmed that child mortality will probably increase further.

3. Insecurity creates psychological traumas.

According to the director of the psychiatric centre in Baghdad, lots of children are faced with serious emotional and behavioural problems as a direct result of the war, the fear, the hate, the occupation. This is what is called Post Traumatic Stress Disorder. Symptoms of this are bedwetting, aggressive behaviour (verbal and physical), sleeping and eating disorders, depression, fear, nightmares, concentration and memory disorders, auto-mutilation, developmental disorders and phobias.
Repeated exposure to war dead and wounded has resulted in widespread emotional and psychological traumas among medical emergency teams of doctors and nurses.
Together with the bad economic situation, the insecurity is today's major problem, causing quite some psychosomatic disorders. There is insecurity because of the presence of the occupation troops. And there is the problem of the inefficiency of the police, which has led to an increase in criminality.

4. Access to health care is severely limited.

The problems with the telephone networks make it difficult to impossible to call an ambulance. Because of the insecurity, patients as well as doctors don't dare go to the hospital at night. We experienced ourselves how, after a major car accident, an unconscious patient could not be brought to the hospital in an ambulance. He had to be brought with a taxi.
High transportation costs are another factor that renders going to the hospital difficult. Same thing with the road blockades. A recent Unicef report states that less than 50% of the Iraqi population has access to the health care they need, because of the insecurity.

5. The hospital infrastructure has not improved over the past year.

We visited some 25 hospitals, clinics and pharmacies. Nowhere had any new medical material arrived since the end of the war. The medical material, already outdated, broken down or malfunctioning after twelve years of embargo, had further deteriorated over the past year. In places where looting had taken place, there is now less material than before, as in Baghdad's rehabilitation centre, which is supposed to provide the entire country of prostheses. Or as in the burns section of the Al Nour Hospital, where there is no possibility of sterile treatment, as a result of which all patients with major burns are doomed to die. Or as in the intensive care unit of the Kadhemya Hospital - which has 8 of the 16 high intensive care beds for Baghdad -, where only three respiration machines are functioning.

6. Medicines and medical material are lacking.

In the hospitals, some specific medicines are lacking, e.g. for burns. In several emergency units, live-saving drugs are not available.

In the ‘popular clinics’, for outpatients, there is a constant lack of medication. The Ministry of Health itself is distributing lists of medication, where for every drug the amount of products delivered is mentioned. We saw one such list containing 32 products. For 10 of them… 0% had been delivered! Many patients don't get their medicines, or they get only half of the dose they need. Results: life quality diminishes, while the risk at early death increases. This is the case for e.g. epilepsy, hypertension, angina pectoris, diabetes, chronic asthma,…

Doctors may prescribe, but patients, who used to get their medicines for free, have to buy them now on the private market. For most of them, this is beyond reach. And many needed drugs are not always available on the market. There are also doubts as to the quality of these medicines, as they are not being stored in optimal conditions.

There is also a lack of disposable material, such as gauze, cotton, syringes, gloves, sutures,… In one ‘popular clinic’ we visited, three doctors had to share one single stethoscope, while one and the same iron tongue depressor was being used for all patients.

7. Depleted Uranium (DU): the population is not informed nor protected.

In August 2003, we were only able to obtain unofficial, ‘off the record’ information from the World Health Organization (WHO) concerning Depleted Uranium. The WHO had asked the US Armed Forces leadership information about the use of DU. They requested to be given a map indicating the places where the US Armed Forces had used ammunition with DU, in order to be able to undertake precautionary measures and prevent the contamination with and the spread of DU particles. The US Armed Forces leadership refused to provide this information. In March 2004, according to WHO sources, the attitude of the US Armed Forces and of the CPA (Coalition Provisional Authority) concerning this topic remained unchanged.
In 2003 and in March 2004, we could personally see that there were no fences nor warning signs around or near the destroyed Iraqi tanks and APC’s (armoured personnel carrier). Children were playing nearby. Most of this Iraqi army material has been destroyed by ammunition with DU. The areas where these tanks and other materials were hit, have not been decontaminated since. The earth around has not been removed. In the neighbourhood of the Baghdad Gate, we saw people cultivating vegetables, unaware of the danger, on fields where in April 2003 many destroyed Iraqi tanks stood. There were no protective measures to be seen. Along the road between Baghdad and Basra still a lot of destroyed tanks can be found. We saw people recycling metal from these tanks. This sometimes happens in an organised way: we saw open trucks, without canvass, fully loaded with pieces of those Iraqi tanks. In the south of Baghdad there is an area where this recycled metal is collected. Again without any protective measure. DU-contaminated dust is spread by the trucks and with the wind.
Medical doctors in Basra told us that they expect a rise in cancers and congenital malformations in a few years, particularly in Baghdad, because that is where DU has been used most. The CPA and the occupying forces have the duty to protect the health of the population. In the matter of DU they are neglecting their responsibility.

8. The plans of the CPA and the Ministry of Health are no solution.

Until last year, a number of contracts for medical material that had been signed by the previous regime were blocked by the UN Sanctions Committee 661. 90 % of them because of a US veto, 10 % because of a British veto. It concerned contracts for a total value of more than 500 million dollar. This money, which came from the sale of Iraqi oil in the framework of the oil-for-food program, was available on a UN account in New York. After the lifting of the sanctions, this money has been turned over to the CPA, and yet those contracts have not yet been executed.

The CPA and the interim government are now talking about new plans to invest in medicines and medical equipment. This can at most be part of the solution, but even then it is a case of 'too little, too late'. There are plans for a new paediatric hospital of more than 50 million dollar. This money would be put to better use by upgrading the existing hospitals. Much of the money will go to expensive US firms, and it can be feared that these investments will have a high PR value. This is a case of combating the symptoms in order to divert attention from the real prevention of illness and disease, by attacking the root causes such as purchasing power, the food situation, the living conditions, the insecurity.

In any case, these investments will not free the occupying power of its duty to guarantee all necessary services to the Iraqi population, as it is stated in the Fourth Geneva Convention. Security, jobs, an income, food and decent living conditions are all part of this. All these factors have a major impact on public health.

9. Appendix: April 2004: US-led troops in Iraq are targeting hospitals, ambulances and civilians.

We received information from first hand field testimonies from health workers in Iraq and eye-witness accounts from Fallujah. According to that information, the US-led occupying forces have:
1. targeted unarmed civilians and used bombs in populated areas of the city. This is indiscriminate use of force, not discriminating combatants from non-combatants. There are several reports of eyewitnesses stating that cluster bombs are used in Fallujah. These reports are confirmed by medical doctors.
2. severely hampered relief work to the wounded.
3. blocked access to Fallujah’s hospital thus forcing doctors and health personnel to set up field hospitals in private homes.
4. targeted ambulances that went about the city to collect the injured.

All of these constitute violations of the Geneva Conventions. They have resulted in the death of hundreds of civilians and extreme misery for thousands of people in Fallujah and many more in the rest of Iraq.
This is comparable to what happened during the US-led invasion of Baghdad last year. We were personally witness of the use of cluster bombs and of US troops shooting at random at civilians, civil cars and ambulances. Then, as now, it was difficult and even impossible for the health personnel to reach the hospitals, because US troops were shooting at everything that came on their way.

Dr. Geert Van Moorter, M.D.
28 april 2004 

Dr. Geert Van Moorter is specialized in emergency medicine and tropical diseases. He made a study and published on child mortality and has experience in public health and post traumatic stress disorder.