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I spent about two weeks in Iraq in January, as part of a non-partisan, fact-finding team. Our six-person team went to Iraq to try to establish a baseline of current conditions and to assess the health consequences to the people of Iraq should a war break out. We visited United Nations agency offices, non-governmental offices, hospitals, primary healthcare centers, water works, sewage treatment plants, electricity-generating installations, food warehouses and distribution points, and local businesses. We traveled all over central and southern Iraq—the part of the country under Saddam Hussein's control—and spoke with many doctors, nurses, other health care workers and service providers.

In January, the possibility of war was still theoretical. Now, it is real.

Whether we consider this war to be legal, whether we consider it to be politically justified, no matter what our philosophical or political stance, we can't escape the fact that the bottom line of this war is that civilians are suffering.

No one knows what will happen in the upcoming weeks and months, but having spent time in this once-thriving country—a country that used to have a modern physical and cultural infrastructure—I confess that I came away feeling that things could not be more bleak. Iraq is like a patient who has been terribly sick for a long time and only recently has begun to show mild signs of recovery. Just as the patient has started to sit up in bed and maybe even take a few tentative steps around the room, he is felled by a virus. In the same way that the patient is more vulnerable to a new disease because he is so debilitated, Iraq is in a desperately vulnerable position because it has been sick, and weakened, for so long.

Nowhere is Iraq's precarious situation more apparent than in the state of its healthcare system. It used to be that people came to Iraq from all over the region for care; its hospitals were state-of-the-art facilities that did an excellent job of delivering primary as well as tertiary care. Then Iraq fought an eight-year war with Iran, U.N. sanctions started in 1988 in response to Saddam Hussein's repressive regime, and the first Gulf War broke out. The result is a healthcare system on its knees.

The sanctions program, administered by the United Nations, has taken a severe toll. Doctors are hampered in their ability to deliver consistent, high quality care because so many medicines aren't allowed into the country. Basically, anything that can have a dual use may be banned. For example, tetanus toxoid was banned for a while because it could be used to immunize soldiers, as well as children. Culture media, used to establish the existence of infectious disease, has been banned because it might be used to grow organisms with biological weapons potential. Sanctions are reviewed every six months and things are then added or deleted from the lists, but the bottom line is that doctors never know which medicines they'll have access to.

With few continuing education opportunities, doctors have had little opportunity in the past decade to keep up with medical trends. For a medical population that is highly trained, once traveled freely to medical meetings all over the world and was current on all the latest treatment modalities, this situation is extremely demoralizing. Patients, of course, bear the burden by having poorer outcomes.

Medical equipment also is in a precarious state. Hospitals have not been able to maintain their equipment or buy new equipment. Ten years ago Baghdad had seven MRIs; now none of them are functional because they can't be maintained or repaired. Some hospitals have only one working X-ray machine that is wheeled from floor to floor.

Perhaps the most insidious problem eating away at the healthcare system is that of the salaries paid to doctors and nurses. On average, doctors make about $10 per month, nurses much less. Naturally, doctors aren't able to support their families on these wages. Highly educated, they often leave public service to look for work at a U.N. agency or set up private practices. Nurses, who can't generate income from private practice, leave the profession altogether; thus, Iraq has a severe nursing shortage.

In spite of all these obstacles, there has been—until this point—at least a functioning primary care system (there's no good tertiary care anymore). Children still get vaccinated and are treated for diarrhea and childhood diseases. The country still produces some basic antibiotics, rehydration salts, and medical equipment. It's all held together with baling wire and chewing gum, but it functions, largely due to the extraordinary talents and ingenuity of the Iraqi people.

And things had been getting a bit better, in general, in the past two or three years. Since 1996 the Oil for Food program allowed Iraq to sell oil on the world market and use the revenues to buy food and other essential commodities. Food was distributed with extraordinary efficiency. Farmers in recent years produced bumper crops and people were getting extra food coupons.

The war could create a total breakdown of these fragile systems. The most pressing problem will be maintaining the food distribution system. Right now, every Iraqi man, woman and child is almost completely dependent on food handouts. If this gets disrupted, it's anybody's guess what will happen next—a massive displaced refugee situation as people move in search of food? What happens if electricity is knocked out in major cities and clean water can't be pumped into houses or sewage pumped out? Even before this war, the U.N. found that 40 percent of the water samples in Baghdad were contaminated with fecal coliforms because of the city's inability to maintain the sewage treatment plants. What happens if large numbers of civilians are wounded, taxing a healthcare system barely able to provide primary care?

In this war, the United States says it is making an extraordinary effort to spare civilians. But even with sophisticated weaponry that can pinpoint non-civilian targets, civilians have been hurt and killed and hospitals are struggling to cope. No one knows what the next couple of weeks and months hold in store for the Iraqi people and their healthcare system.

What we do know for sure is that the patient is very sick again and will need an extraordinary amount of help if he is ever to get out of bed.

Dr. Waldman is professor of clinical population and family health at the Mailman School of Public Health. His team, co-sponsored by the Brooklyn-based Center for Economic and Social Rights and the Boston-based Physicians for Human Rights consisted of a public health lawyer, two public health physicians, an emeritus professor of nutrition, and a disaster relief expert. For more information on Dr. Waldman's trip, see Benjamin et al., The Humanitarian Costs of a War in Iraq. Lancet 361(9360):874, 8 March 2003.


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