Dr.Safaa T. Bahjat MD

INTRODUCTION

After 6 years the US-led occupation of Iraq unleashed a civil war estimated by WHO to have killed at least 100,000 civilians, with around 2 million Iraqi refugees having fled to Syria and Jordan, while another 2.8 million people have been displaced within Iraq. The United State's agency for international development (USAID) estimates that Sulaimaniyah province host almost a half a million internally displaced people, the largest displaced population outside Baghdad. As sectarian violence continues through out Iraq including in cities near Sulaimanyah, like Mosul and Kirkuk, the US Government has doubled spending on displaced people to about $120 per person per year/ homes. In 2008, the Government of Iraq offered grants of about $600 to families that return home. So far, less than 1% of displaced people have accepted that offer. In the Sulaimanyah camp, 36 year old Ossam KaKhalin Shalan describes his plight in stark terms. "We were forced from our home in Baghdad by insurgent militias, and then the house was destroyed by government troops" he says over the cries of a baby struggling in his arms." This child was born in a tent here in the camp and has no certificate of birth. My wife was afraid to go to the hospital to deliver it. But we will stay here if we can. Even if we have to beg in the streets". A local non governmental organization, the Kurdistan health foundation report, showed that the refugees, most of whom are Sunni Arabs, are largely blocked from accessing Kurdistan 's public health system. The problem is a part of 'a pattern of neglect" on the part of Kurdish officials. The camp's unofficial Mayor, Ayad Manfee, also fled Baghdad when fighting destroyed his home. After a year under plastic tarpaulins at the edge of Sulaimanyah , he and his wife Lyla complain that the Iraqi Government has yet to transfer their food ration cards from Baghdad, thus denying them access to the system of government food support established for poor people during the Saddam era. "When I went home to collect the food", says Lyla Manfee, "I was threatened with death". The Manfees are also unhappy with aid groups. "The Red Cross brings us water, but, for the most part the humanitarian groups come here, take a lot of photographs, make a lot of promises, and then we never hear from them again", says Ayad Manfee. He reserves his parting shot for the US Army. "We had an American general come here and promise us toilets. But nothing happened".

After 6 years of civil war, preceded by a decade of International economic sanctions, Iraqi health officials says health-care conditions across the country are improving, but are still desperate. Mortality rates for children younger than 5 years (46 per 1000 live births) and maternal mortality rates (84 per 100 000 live births) are far higher than in neighboring countries, and far higher than before the US invasion in 2003, when these indicators had already tripled after a decade of economic sanctions. One in eight deaths is violence-related. .38% of pregnant women
are anaemic. Diarrhoea and acute respiratory infections, further compounded by malnutrition, account for about two-thirds of deaths in children younger than 5 years. The World Food Programme estimates that 22% of children under 5 years are stunted due to malnutrition. At the peak of the most recent cholera period, in early 2008, 4,697 confirmed cases were reported in 46 districts . Only one in three Iraqi children younger than 5 years has access to safe drinking water, UNICEF estimates, and 14% of children are born underweight. In a panel discussion last summer , medical researchers from Baghdad, al-Nahrin and Al-Mustansiriyah University stressed that the war has had a devastating effect on public health care, especially for women and children, with many pregnant women unable to reach hospitals for delivery, routine immunizations severely reduced, medical supplies disrupted, electricity cut at hospitals, and primary care particularly badly affected. 'Much of the disease burden is attributable to environmental risk factors, such as improper management of hospital hazardous waste, unsafe water, poor hygiene, poor living conditions, and unsafe food", says the UN." Violations against children are being committed on a large scale and include child recruitment, attacks on schools and hospitals, killing and maiming by indiscriminate attacks and lack of humanitarian access due to insecure conditions". A recent study of 210 Baghdad physicians by researchers from the Al Mustansiriyah University College of Medicine suggests physician competence is also a worry, with only 20% of physicians who have undertaken postgraduate studies aware of the principles of evidence based medicine." The state of medical knowledge among physicians, even those conducting research, is disastrous", says Amir Jalal Mosawi, Editor of the New Iraqi Medical Journal and head of pediatrics at University Hospital in Al kadhimiyia, Baghdad." When we receive a double-controlled study, I can almost be sure it is a fake". Al Mosawi credits the Iraqi Ministry of health for establishing a research bureau, at a time when health budgets for 2009 are being revised downwards because of the global financial crises. But for the present he says, researchers can do little more than gather data and wait for help to design studies.

In Southern Iraq, health-care delivery remains severely constrained by violence. Although the
Iraq Ministry of Health estimates 200 physicians have been killed since the US-led invasion, the Iraqi Medical Association put that figure at 2000 doctors .The Ministry and the association estimates that nearly half of the country's 34,000 doctors have left the country. In November 2006, deputy health minister Ammar al-Saffar, a critic of US reconstruction efforts who called for greater investment in health reconstruction was kidnapped from his Baghdad home by armed men. He has not reappeared. In February, 2008, there was an assassination attempt on the deputy Dean of Baghdad University's School of Medicine. In March, Khalid Nasir al Miyahi, the only neurosurgeon in Basra was kidnapped and murdered. In December 2008, the Dean of the University of Mosoul's School of Medicine was wounded by gunmen. At the Iraqi Medical Association's 2008 annual conference, which was held in Syria, several participants from Iraq were prevented by the war from attending. Official efforts to attract physicians back to the country have so far yielded little result. The government's recent decision to allow physicians to carry weapons for self-protection has been criticized by many for further undermining confidence in physician's safety. A study produced by the Iraqi association of university lecturers notes that 235 Iraqi academics have been murdered since 2003 and a further 294 have been kidnapped or threatened. Medical professors have disproportionately borne the burnt of this violence, the study notes. At Baghdad University, for example, 11 medical professors have been murdered, the largest group among the 71 faculties. "Neither the occupation forces nor Iraqi ones tried to stop or prevent violence against academics" said the Lecturer's Association. Although much of the blame for the violence against physicians and medical facilities is placed on insurgents, government actions have also been implicated , most recently in Baghdad's densely populated Sader City district, where municipals officials estimate 925 people were killed and 2,605 were wounded as US and Iraqi government military operations tensified in early 2008. After government forces surged into the area in April, Sadr City General Hospital and some 12 ambulances were damaged by US missiles, the UN reported. According to Yassin Al-Rikabi, director of Mohammed Bkjr Al Hakim Hospital in Al Sadr city, in early May, 40 Iraqi soldiers raided the hospital and arrested 35 staff members on suspicion of having treated Mahdi Army Fighters. The soldiers temporarily forced the closure of the hospital. Five of 20 public health centers in Sadr City , which has a population of 2 million, closed temporarily during this period, the UN reported. "The military operation took it's residents unprepared for basic needs and deprived them of access to basic services such as electricity, fuel and water supply and access to health care" UN observers wrote. "The situation was further aggravated by the imposition of a 48 hour curfew which prevented the movement of ambulances in and out of Al Sadr City and the transport of wounded civilians to hospitals".

Although the US government has devoted $50 billion to the reconstruction of Iraq since 2003, so far less than $1 billion has been devoted to health-care infrastructure, far less than has been spent on new vehicles for the Iraq army. Of the 243 US Government advisers working within Government of Iraq ministries, only ten work on non-health issues. From a 3.6 billion fund intended to allow the US military commanders to "meet the needs of the communities in which they operate", expenditures on security increased 600% to 250 million his year, whereas health care expenditures diminished by 36% to $14 million and water and sanitation spending declined by 73% to $44 million. After the US led invasion in 2003, the White House directed the Pentagon to establish a team of 30 experts led by Assistant Secretary Of Defense for Health Affairs William Winkenwerder and Jim Haveman, a former Michigan health official, to work with the Iraq Ministry of health on health-care reconstruction. In 2004, the team helped establish a new national health care strategy, expanded the health budget 30-fold to $1 billion, and rebuilt the ministry's headquarters. It also pushed the government to expand primary care, rationalize drug distribution, and recruit doctors to return from exile abroad." One of the biggest problems we had once we had a billion dollar budget was to get people to spend money". Haveman later explained .The problem persists. Of the $192 million allotted for long term projects within the Iraq Ministry of Health's 2008 budget, only a small fraction was spent, according to the US department of defense. For its part, the US passed much of it's funding for the reconstruction of Iraqi clinics and hospitals to US engineering firms that were later severely criticized by US Government auditors for failure to honor contracts. Audits of US Government contracts with the American engineering giant Parsons Delaware Inc to build 150 public health centers across Iraq found that most facilities were only partially completed, and only six were finished. US auditors also criticized USAID for its management of a construction of 94- bed children's hospital in Basrah. After the Congress allotted $50 million for the project in 2003, USAID awarded the contract to the US-construction giant Bechtel. When Bechtel's bills spiraled to $170 million, USAID, which never appointed a project officer to oversee Bechtel's work on the hospital, did not notify Congress. In Baghdad, outgoing US ambassador Ryan Crocker says that after spending tens of billions to bolster Iraqi police and military, US reconstruction efforts will increasingly focus on health care and education. But he does not predict this will involve large investments: "It is not about building schools and hospitals anymore", he says. "I think relatively small inputs to help Iraqis on policy reforms can pay substantial dividends later. The whole focus has been, and is, shifting from major reconstruction into helping with governance, helping with capacity, helping with policy reform, and protecting investments".

In Baghdad, the country's most popular province, 48% of the regional budget is devoted to security, whereas health care receives 1% of provincial finance. In the oil rich but violent city of Kirkuk, on the southern edge of Kurdistan, the Institute for War and Peace Reporting notes that families of patients in Kirkuk Hospital's neurosurgery units are expected to purchase basic equipment required for operations, and that basic equipment such as surgical drills are worn beyond repair, as is the case in Baghdad, provincial officials in Kirkuk devote about 1% of their budget to health care, whereas 18% of the budget in Kirkuk is earmarked for oil and gas field rehabilitation.
Investment in oil and gas production is expected to boost export revenues that will help the government expand health-care budgets .At a health-care reform conference last June, officials and parliamentarians called for an increase in national budget allocations for health from 5.3% (or $43 per head) to 10%. Although the government resisted calls for budget increase, in early December, 2008, after concluding a poliomyelitis campaign which, with WHO and UNICEF support ,vaccinated 97% of Iraq's 5 million children, the Ministry of Health announced plans to build six new hospitals and 1000 clinics.

Paul Webster.Reconstruction efforts in Iraq failing health care.JAMA 2009;22-28.