Feature

Continuing collateral damage

The health impact of war goes far beyond the deaths and injuries in combat. healthmatters asked Jane Salvage and Mike Rowson of Medact for their assessment of the situation in Iraq

How many lives were lost during the war, and since?

A rough count is all we can do at the moment. Between 7,500 and 9,500 civilians were reported to have died from the direct effects of war up to 20 October, but the number dying from indirect effects – such as infant malnutrition – is probably far greater. The number of soldiers who died is unknown. The US estimates 2,320 Iraqi military deaths from fighting in and around Baghdad alone; others have estimate deaths of between 13,500 and 45,000 based on the 3-10 per cent casualty rates in units around Baghdad. Around 394 US and UK combatants had died up to 20 October.

Are the weapons used during the conflict likely to have any continuing impact on health?

Coalition forces used depleted uranium weapons that leave a chemical and radioactive residue. Prolonged exposure to this toxic dust can lead to kidney damage and lung cancer. A widespread impact on health and the environment comes from contamination of the soil and groundwater reserves in and around the impact area. Yet the US said it had no intention of cleaning up residues from DU weapons.

What about landmines and unexploded munitions?

Landmines and unexploded ordnance constitute a serious long-term health hazard. Iraq’s previous wars had already bequeathed a terrible legacy of minefields, now even worse. Iraqi soldiers abandoned large quantities of ammunitions, and coalition troops used cluster weapons which left thousands of unexploded bomblets on the ground. Even intense clearance work can clear the mines only slowly. Meanwhile the explosive remnants of war will kill and maim innocent civilians every day, as well as livestock.

Is there likely to be any long-term environmental impact?

The conflict has added to the chronic environmental stresses that have accumulated over the last 20 years. Smoke from oil fires and burning trenches caused air pollution and soil contamination. Heavy bombing and movement of large numbers of vehicles and troops further degraded ecosystems. Radioactive materials have been dispersed into the environment. During the looting of Tuwaitha nuclear power plant, people tipped uranium on the ground so they could use its containers to store food and water. Some 150 of the 500 containers are still missing.

How does a conflict like this affect the mental health of the civilians caught up in it?

The short and longer-term effects on civilian mental health include post-traumatic stress reaction, psychiatric illness, behavioural disturbance and developmental delays in children. All this was predictable, but few of the WHO guiding principles for maximising mental health protection in emergencies were heeded.

And what about the soldiers?

Hard data on this war is lacking but experience elsewhere suggests that many combatants suffer mental distress, sometimes lasting many years. Coalition forces have access to some psychological support, but it falls far short of what is needed. Iraqi combatants have no formal help at all, and lost their jobs when the military was disbanded.

Are there specific effects on the health of children, for example through infectious diseases?

There are serious concerns about children, whose health was already weakened by the aftermath of previous wars, sanctions and the brutal regime. Post-war shortages of clean water, adequate food and power led to an increase in certain diseases extremely hazardous to the under-fives. A post-war assessment by UNICEF in Baghdad found that acute malnutrition or wasting had nearly doubled from four to almost eight per cent, and that seven out of ten children had suffered diarrhoea. There also appears to have been a rise in vaccine-preventable and waterborne diseases.

What has happened to Iraq’s health service? How is it coping with the aftermath of war?

The health service is in a parlous state. Described by WHO as ‘first class’ in the 1980s, it is now very run down, with severe shortages of drugs, equipment and staff. Professional training has been substandard for years and standards are low, especially in fields like primary health care and rehabilitation that should be post-war priorities. The insecurity and violence prevailing in many parts of the country means that health professionals are scared to go to work or unable to get there.

But the health service will benefit from reconstruction?

The World Bank estimates that about $1.6bn is needed to rebuild the Iraqi health sector. Original plans to invest heavily in tertiary level facilities seem to have been scaled down, as people recognise that primary care needs a strong boost after the ten-year rise in communicable disease and infant and child mortality. There is also a human resource crisis due to dictatorship and the effects of three wars – many health professionals have left the country. Nursing and midwifery are in particular need of development.

What are the major priorities now for protecting and promoting the health of Iraqis?

Little can be achieved until the country is made secure and free of violence and crime. The priorities include providing clean water, better sanitation and adequate, balanced nutrition, while teaching basic principles of hygiene and infection control. Basic primary health care must be made available in all areas, to get the national immunization campaign running and to protect the health of vulnerable groups through antenatal care, trained attendance in childbirth and so on.

Who did the research for the Medact report? How did you get the information you needed?

Sabya Farooq, an epidemiologist with Iraqi roots, carried out the work with a range of technical advisers. We kept in close contact with people working in international agencies as well as Iraqi health professionals. But information is still scarce. Information systems need to be re-established urgently for disease surveillance. The occupying powers have a duty to collect and disseminate such data to assist reconstruction and tackle Iraq’s pressing health needs.