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On Oct. 24, a United Nations conference was held in Madrid for donors to Iraq to discuss how best to rebuild the country. According to Dr. Richard Garfield, professor of nursing and coordinator of the World Health Organization Nursing Collaborating Center at Columbia, Iraq will benefit most when it receives funding for local community health and decision-making activities, because these will lay the foundation for a democracy. Dr. Garfield frequently visited Iraq from 1996-2003 to collaborate with UNICEF, the World Food Program, and the Iraqi Ministry of Health. Since the 2003 war, he has worked in Iraq for WHO and UNICEF to assist in reconstruction, manage reactivation of health services, and prepare the post-Oil for Food U.N. program.

Newcomers to Iraq are shocked to see how competent and ‘normal' Iraqis in positions of authority are. Iraq doesn't at all resemble what we in the West think of as a typical underdeveloped country. But looks can be deceiving. Economic and social conditions in Iraq have regressed to the levels that existed there 30 years ago. By January 2004 optimists hope to get the country back to its January 2003 state.

Iraqis are skilled at carrying out orders, but not at collecting information, assessing needs, setting priorities, or monitoring program implementation. All of these facets of life were previously controlled from the president's office and anyone taking initiative in these areas risked his or her life. Now things are upside down – ministries and businesses can plan freely, but the lack of infrastructure and security prevents implementation.

American advisers underestimate the importance of health and education to establishing a new order in Iraq. A major point of pride to Iraqis is that this year, for the first time, national university exam answers were not sold before the day of the test. This happened because educators, rather than the now-defunct ministry of higher education, administered the exams. Here are the seeds of a meritocracy and a pride in national competence.

The aftermath of the war could have gone differently. In Europe and Japan during World War II and even during the Vietnam War, civil affairs brigades of the armed services brought more than symbolic assistance to captured territories right away. The brigades had resources and training in key fields, such as public health and communications. Today's much leaner armed forces are drenched in Star Wars-type equipment but are ill-prepared to help serve or administer liberated territory. In Iraq, this meant that political decisions after the war included purging of even mid-level Ba'athist administrators from all government offices and disbanding Iraqi armed forces. The goal was to make a clean sweep, starting from scratch with new institutions and personnel. This intention led to the appointment to leadership posts of Iraqis who had been out of the country for years or decades. Unfortunately, each of these decisions contributed to greater instability after the war, putting off the time when genuine self-rule could occur.

Self-governance doesn't start at the top; that is imposed governance. Whoever the United States appoints as leaders must be protected by U.S. troops for an extended period. Failure to do so is like throwing oil on the many Iraqi fires that we have helped ignite with Saddam's overthrow.

Calls for the United States to transfer authority to an Iraqi government within months and for U.S. troops to withdraw at this time will cause more harm than the war itself, as it would likely lead either to civil war or theocratic rule. Security is the problem that got us into Iraq, and security is the key issue for that country's future.

Who imagined before the war that the Iraqi armed forces would collapse and disappear so quickly? And who imagined that the end of the war would mark the beginning of long-term post-war instability. Since the end of major hostilities, more U.S. troops have died than during the actual 42-day war and the U.N. has suffered its biggest attack in its history. Yet, in the midst of these gruesome conditions, many aspects of daily life are slowly improving for most Iraqis. Police have broken up kidnapping rings and more children are going to school. Merchants selling cars and air conditioners continue doing a brisk business as people invest in their future by buying more goods.

The most important question is not when authority will return to Iraqis but whether Iraqis will be prepared to assume that authority. What the United States does now will determine the answer.

First, we must help reestablish a semblance of normalcy. This means health care, education, and jobs. We should have poured in billions from day one; since we didn't, we are spending many more billions just to hold the country together. It is either going to be pills and school books or bullets, and the bullets now cost us much more than pills and books.

Second, Iraqis at all levels of administration need training. Iraq must become a management training school if its people are to run their own country and spend their petrodollars well. The United States, other Middle Eastern countries, and the world community have the expertise and can share it with Iraqis. Gutting the administration set them back; now we have to help them take giant steps forward.

Third, we have to help Iraq develop democracy from below. Local and regional elections are the way to start. Most Iraqis yearn for democracy. We can help them learn it best step by step.

Men stand in mile-long lines under the burning sun for hours to sign up for menial jobs offered by the Coalition Provisional Authority (CPA), but half of all men in the country and even more women are unemployed. Again, health and education are key. These are the fields where women, especially, can enter public life.

The current funding request to the U.S. Congress for health care focuses predominantly on hospitals, responding to aspirations of doctors for good conditions for sophisticated care. Yet most of Iraqi's health needs are basic and can be solved better, and much more cheaply, at home or via primary care. Iraq has a shortage of doctors but has even fewer nurses and almost no community health workers.

In their communities, people can become enfranchised. In local institutions, Iraqis can negotiate and direct their lives. It is only out of this soil that democracy and economic viability will grow. No matter what sacrifices our troops make, success will not come from winning military engagements but rather from sharing authority and responsibility, not only with other U.N. countries but with a broader range of U.S. citizens not currently represented by the CPA.

Pundits argue that we did this nation-building before and it worked, so stay the course. But the Marshall plan was led by civilians, involved local authorities, required partnership, and focused on strengthening local administrative skill. This will work in Iraq as well, but major changes must be made if we are to get it right.


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