The Iraq War and Global Public Health

The images of U.S. soldiers helping Iraqis topple statues of Saddam Hussein reminded me of the late novelist, Truman Capote's favorite aphorism. He often quoted the warning ascribed to Carmelite nun St. Teresa of Avila: "More tears are shed over answered prayers than unanswered ones."

As a mere observer, I worry that the answered prayers of President Bush may bring about a number of social, economic and political problems in the Middle East — and beyond — that we have not adequately considered.

But as a physician, I am almost frantic about how the war and its aftermath will affect the health of the people of Iraq. And, by extension, I am gravely concerned about the spread of those problems to other countries in the region — and those seemingly far away.

During Saddam's reign of terror, the dictator and his lackeys often bragged about their nation's wonderful hospitals and its cadre of well-trained medical professionals.

These boasts may have resembled the truth in the years before the first Gulf War in 1991. But for those who have paid close attention to global health matters in the decade since, Iraq has been in desperate need of intensive care for some time.

Before the 1991 Gulf War, Iraq's health conditions were comparable to those of other middle or high-middle income countries. But since that conflict, the degradation of its infrastructure has been associated with a marked deterioration of its people's health.

During the early-to-mid 1990s, the combination of mismanagement of the public health system by Saddam's regime and the UN sanctions on Iraq helped create a dire situation.

The Iraqi government was only able to meet roughly 10% of its people's health needs — and 50% of their daily food requirements.

Since 1995, when Iraq was permitted to again export oil, things improved — but only slightly.

According to the World Health Organization and UNICEF, life expectancy at birth was a paltry 58.7 years for men and 62.9 years for women in 2001. More disturbing, the infant mortality rate — long considered the most sensitive marker of a community's state of health — was a staggering 98 per 1,000 births.

As a point of comparison, the figure for the United States — which has one of the highest infant mortality rates among developed Western nations — is about 10 per 1,000 birth.

In the Eastern Mediterranean region, Iraq has the fifth-highest infant mortality rate. Only Afghanistan, Somalia, Djibouti, and Sudan are higher. Even Iran has a much lower infant mortality rate of about 40 per 1,000 births.
Of the 24.5 million people living in Iraq, almost half are children. Sadly, one out of every eight of these youngsters dies before reaching the age of five.

There is a remarkably high incidence of communicable diseases among Iraqi children, including those that are wholly preventable with vaccines — such as measles and outbreaks of diarrhea due to a lack of adequate sanitation and clean drinking water.

About one-third of these children are malnourished. One-quarter of them do not have access to safe, clean water.

Among adults, the incidence of tuberculosis has nearly tripled over the past decade — growing from 46.1 cases per 100,000 people in 1989 to 131.6 per 100,000 in the year 2000.

Serious outbreaks of malaria have also been observed in Iraq. That is not to mention poor records of providing treatment — let alone prevention — for non-infectious killers, such as cancer, cardiovascular diseases and diabetes.
To make matters worse, 18 million Iraqis lack access to adequate food, according to the WHO. Moreover, almost 60% of the population relied extensively on the Hussein regime for monthly allotments of food.

What makes these deathly statistics even more frightening is that they were all gathered in 2001 — well before the U.S. military offensive began.

And since the beginning of the war in mid-March, the hospitals, health care facilities and water sanitation resources that may have existed are in a state of ruin.

Even the most casual television observer can tell you about the shortage of medicines and other life-saving interventions, which was made even worse by the looting and rioting that erupted in the streets of towns and cities across this nation.

In the months to come, we can be certain that health matters — in the form of treating the wounded, staving off epidemics, mental health problems and a host of other illnesses — will only become strikingly worse.
Moreover, the United Nations World Food Program recently estimated that the Iraqi people will require at least 480,000 tons of food per month. Current deliveries fall far short of this target.

International aid agencies acknowledged the far more pressing problems of providing medical supplies, health care and clean water in Iraq.

But, as of this writing, no one quite knows for sure where the billions of dollars and the army of health care professionals to address these problems will come from.

All of this gloomy news is, however, not an attempt to offer a political or social commentary on the war against Iraq or its former dictator.

What seems far more important than gloating about toppled statues, however, is rapidly writing a prescription for the health of those left behind in devastated nation.

We should not forget that the potential epidemics that may arise from Iraq's poor health conditions are not likely to be constrained to the Middle East.

One of the most likely contagious culprits is cholera. The microbial cause of cholera — a comma-shaped bacterium called Vibrio cholerae — causes massive diarrhea and dehydration. If left untreated, it can lead to death in less than 24 hours after symptoms begin.

The current conditions in Iraq, with disrupted water lines, sanitation plants and sewage systems in many towns and villages — make it easy for gastrointestinal microbes like cholera, and many others, to gain ground.

With antibiotics and intravenous fluids, the mortality rate of this infectious killer can be contained to about 10%. But when there are little or no such supplies — exactly the situation we are currently seeing in Iraq — the death rate of a potential outbreak shoots up to 50% or 60%.

While not as easily transmissible as a respiratory infection like SARS, cholera and other diarrheal disorders are still likely to spread as people flee from Iraq to neighboring countries. Given the less-than-ideal health conditions in Syria, Iran and even rural Saudi Arabia, this is far more than a theoretical concern.

The fact that we live in a global village means that scourges we once thought conquered can not only rise again — but spread fast. After all, history teaches us that few influences are as strong at helping epidemic diseases gain ground as war.

Truman Capote's advice to be careful about what you pray for is a clever way of explaining that once our prayers come true, they often give rise to problems we never really thought much about.

Saddam Hussein's fall may turn out to be an excellent proof of such an axiom.

In the excitement of planning the massive military offensive, there is little evidence that the United States ever considered the entirely predictable health problems and food shortages that have come in its wake. Most seriously affected, tragically, will be millions of innocent children.

Unless the American government and its coalition forces act immediately to orchestrate the more pressing war against disease and famine now facing Iraq, its impact on the world's health is certain to be even more devastating than those who planned “Operation Iraqi Freedom” ever imagined.