Feature

The cost of ‘winning’

How can a destroyed nation cope with the human casualties of war? Steve Iliffe reports

The Gulf War may go down as the most one-sided in history. Allied casualties were minimal, but the civilian and military death toll in Iraq was enormous — and continues to mount daily with the repression of the Kurds, and the sporadic fighting in the south.

The full horror of the bombing of urban areas, and the final massacre of the disintegrating Iraqi army, is only slowly emerging into public consciousness. Meanwhile electricity is hard to come by, along with pumped water and basic medicines.

Those coagulated by the fireball inside the Amariya bunker, after it had been struck by smart bombs may have been the lucky ones. They have avoided survival with burns beyond even minimal supportive treatment, simply because health care has broken down. They have avoided operation under ether because modern anaethetics have run out. They cannot catch polio or diphtheria. They have avoided developing kidney failure, and none will have dialysis withdrawn for lack of supplies. Whilst their families and friends wail at the horrific sight of incinerated corpses, for the survivors the worst may yet be to come.

When a delegation of senior members of International Physicians for the Prevention of Nuclear War (IPPNW) visited Jordan and Iraq after the occupation of Kuwait but before the coalition attack on January 17th, they found health services on the brink of collapse.

Jordan had become an under-developed country virtually overnight, losing 40% of its GNP because of the UN sanctions on Iraq. Its health services consisted of about 3,000 hospital beds, of which 24 were for burns injury care, and no reserve facilities that could be mobilised. Over three quarters of a million ‘third country’ refugees (workers from Bangladesh, Sri Lanka, India, Pakistan and the Philippines) had entered Jordan from Iraq, along with 200,000 Jordanian ‘guestworkers’ and their 40,000 primary age schoolchildren. Many of these children were surviving on tea, bread and tomatoes, and UNICEF reported the appearance of malnutrition in the refugee camps.

In Iraq shortages of antibiotics, of drugs for the treatment hypertension and diabetes, and of surgical supplies — scalpel bladed and sutures in particular — were apparent. In the Saddam Central Paediatric Hospital, a leading teaching hospital and the major medical institution for children in Iraq, 50% of beds had been closed following an exodus of nurses but admissions had doubled, as had mortality rates. When the IPPNW delegation visited, the hospital had run of the intravenous penicillin (although there were some intra-muscular preparations left), disposable transfusion units, nutrient fluids for allergic infants. Anaethetics were running low, as was formula milk for babies. Incubators were unusable for lack of spare parts, but even so the drastic nursing shortage had left one nurse in charge of thirty functioning incubators.

At another teaching hospital, the Saddam Medical City Hospital, open ether was being used because there were no anaethetics left. People needing dialysis had had their treatment schedule changed from twice weekly to once fortnightly for lack of heparin, whilst kidney transplantation had virtually ceased because the drugs needed to stop rejection of the donor kidney were so scarce.

Whether the necessary supplies had failed to evade sanctions, or had simply been rerouted to the military hardly matters now, for what remains of the Iraqi army’s medical corps after the destruction of the forces occupying Kuwait. Iraq, already a country where physical disability was commonplace, entered the war with a health service that could not cope with its existing caseload.

Burn injuries are likely to have been suffered by large numbers of people, civilian and military alike. Extensive burns are difficult to treat and consume large amounts of resources; US studies suggest that 10 days inpatient care are needed for every 10% of the body surface with full or deep-partial thickness burns. At the outset of the war Iraq had 100 hospital beds suitable for people with severe and extensive burns. These would have been filled in the first phase of bombing, with space for new casualties becoming available only one to three months later. The resources needed to treat different levels of burn casualties are indicated in the box.

Many Iraqis will be scarred for life by their experience of the war, and the scale of this injury must surely shape society’s image of itself, its place in the world and its prospects. Perhaps talk of competing for contracts to reconstruct Kuwait or of exacting reparations from Iraq should be subject to a little censorship, and a plea be made instead for medical supplies, equipment and personnel to be channeled to a suffering nation?

Projection of Facilities and Staff needed to treat burns victims

Number of

burn victims 1,000 5,000 10,000 20,000 30,000

Beds needed (1) 1,000 5,000 10,000 20,000 30,000

Blood needed (2) (pints) 5,000 25,000 50,000 100,000 150,000

Doctors needed (3) 125 625 1,250 2,500 3,750

Nurses needs (4) 500 2,500 5,000 10,000 15,000

1 assuming casualties occur over a short period of time

2 assuming the average burn injury is 25% of the body surface, needing 5 pints of blood (treatment traditions differ in different countries — Iraqi burns specialists use more blood than would UK or US burns specialists)

3 assuming 1 spcialist burn physician/surgeon needed to treat 8 patients

4 assuming 12 hours shifts with 4 burns patients per nurse