Last week’s blog post on the displacement issue in Iraq’s ongoing humanitarian crisis highlighted an important phenomenon; the violence has come to intensify existing development problems in Iraq. Among the most important of these problems are health, food security, and WASH (Water, Sanitation, and Hygiene) programs.
- After 4 decades of healthcare decline in Iraq, the current crisis has diminished the capacity of hospitals in places like Anbar, and overwhelmed others in the Kurdish Region of Iraq.
- While immediate food security is being well addressed by international organizations, rising food prices and the disrupted harvesting season threaten the ability of host communities to take in displaced Iraqis.
- The poor state of Water, Sanitation and Health (WASH) programs in Iraq was compounded by the recent violence, leaving Iraqis at high risk of Cholera and water borne diseases.
Iraq’s Health Problems prior to the Crisis:
Throughout the 1970s and into the early 1980s, Iraqi health care was outstanding. With a free health care system in 172 hospitals and 1200 primary health-care clinics, staffed with medical professionals graduating from top universities in the UK and Germany, Iraq was a regional leader in healthcare. Yet, when Saddam Hussein came to power and the Iran-Iraq war began, resources were diverted away from the medical sector. After nearly a decade of decline in healthcare spending, sanctions following the 1991 Gulf war further undermined Iraq’s healthcare system. A mass exodus of health care professionals occurred as Doctor’s salaries dropped to only $30 a month. Iraqi hospitals fell behind on health care knowledge as hospitals had no access to foreign journals, textbooks or internet. Lastly, the sanctions placed an embargo on many essential medicines, particularly those used for combating simple bacterial and fungal infections. For more see “Healthcare under Sanctions in Iraq: An Elective Experience” The US invasion in 2003 further hampered Iraq’s health system. Damage and looting following the invasion caused a large loss of equipment and pharmaceutical stocks. While nearly $53 billion in assistance schemes were implemented, many doctors had fled the country and challenges remained. 78 percent of Iraq’s health professionals in Baghdad alone fled by 2007. In the years leading to the crisis, healthcare was in poor conditions. The World Health Organization (WHO) reported in 2011, that Iraq had 7.8 doctors per 10,000 people, a rate at least two times lower than the surrounding neighbors. In areas of security concerns, this number is lower. IRIN reported that nearly all families (96.4 percent) have no health insurance and 40 percent of the population deems the quality of healthcare services to be very bad. By the start of the current crisis, Iraq’s hospitals and clinics were already understaffed and in poor conditions. The crisis has merely exacerbated Iraq’s healthcare deficiencies.
Iraq’s already deficient healthcare system is overwhelmed by the crisis. Some hospitals and clinics have closed in areas of fighting. In other areas health services struggle to operate at full capacity.The fighting has damaged hospitals, disrupted key supply chains, reduced access to fuel and electricity, and caused an exodus of medical personnel. Hospitals in Mosul, Tikrit, and Fallujah have been damaged by fighting. The Fallujah hospital was targeted multiple times by the Iraqi government from May through July. On July 20th, the hospital in the town of Shirqat, between Mosul and Tikrit, was bombed. Attacks on these hospitals, and others have severely diminished access to medical services for those most in need. Other hospitals, although unscathed, are running at low capacities. The ongoing insecurity has caused supply and personnel shortages in hospitals across central Iraq. The dwindling medical staff in Iraq before the crisis are beginning to leave for security reasons. Most recently, the General Hospital and Primary Health Care Center in Sinjar reported that all health staff fled due to the conflict, leaving Sinjar without medical personnel. Cold chains, required to keep key medicines cold, are disrupted due to a lack of electricity, fuel supplies and insecure transportation. This means that some medicines delivered areas of conflict, may not remain effective for a long time if refrigerators stop working due to a lack of electricity. Hospitals in more secure areas, like the Kurdistan region, are now overwhelmed. Large influxes of IDPs recenlty overwhelmed health services in Dahuk Governorate, particularly in Khaneke, Sharya and Ba’adra where the number of consultations tripled. The Health budget of the region is now overstretched, which leaves hospitals in the Kurdistan region not only understaffed but underfunded as well. International organizations have helped relieve some of the pressure by providing mobile health clinics and key supplies and personnel to overwhelmed hospitals. Delivery and needs assessments will continue to be difficult processes as the conflict continues. (For more see the most recent WHO update on health) However, the sustainability of such a health approach is in question. With thousands of Iraqi medical professionals fleeing the country, Iraq’s healthcare system may be left severely diminished for years to come. Communicable Diseases: The displacement of millions of Iraqis and their poor living conditions has raised concerns of the spread of diseases like Measles and Polio. Since January 2014, over 860 Measles cases have been documented in Iraq. Measles is a highly contagious respiratory disease which causes fever, runny nose, cough and a rash all over the body. Children under 5 and adults over 20 are at risk of complications like pneumonia if left unvaccinated. Measles isn’t new to Iraq, in 2008/2009, a large outbreak of measles spread throughout the country, largely due to the absence of a large scale vaccination program. Like Measles, Polio returned to Iraq with two cases back in April of 2014, after a 14 years absence due to a lack of widespread vaccination. With such mass movements and the very contagious nature of Polio, a significant risk exists for a potential outbreak. To respond, UNICEF, WHO, and others have conducted multiple vaccination campaigns, with its most recent campaign vaccinating 4 million children throughout 13 Governorates. With the addition of 4 million the total for children vaccinated against polio since march stands at around 22.5 million. Yet, access and IDP movement constrained these efforts, leaving many children unvaccinated. Non-Communicable Diseases: Disrupted supply chains for medicine limit access of Iraqis to key medicines for conditions like asthma, diabetes, hypertension, and others. The medicine that does exist is limited and often too costly for displaced families deciding to spend their money on food and shelter rather than key medicine. For Iraqis with Asthma, particularly children, life in displacement camps and makeshift shelters is hellish. Daily sandstorms, hot weather, and open sewage can induce and exacerbate Asthma attacks. WHO and other organizations have distributed necessary drugs, but its unclear whether all needs have been met. The access and affordability of drugs to treat chronic illnesses is an ongoing challenge in Iraq. Maternal Health: UNFPA expects that, with overstretched health facilities, the number of unassisted childbirths may rise. After assessing the Erbil Maternity Hospital, UNFPA noted that the caseload had doubled with up to 20 Caesarean (C-section) cases every day and an average time from birth to hospital discharge of 3 hours! UNFPA warns that about 250,000 women and girls, including nearly 60,000 pregnant women, are in need of urgent care. With 10 million dollars, allocated from the $ 500 million donation from Saudi Arabia, the UNFPA has mobilized support in affected areas by distributing thousands of “dignity kits”, provision of basic equipment and supplies for reproductive health care and normal childbirth, and assistance to 85 hospitals and maternity centers as well as 207 primary health centers. Mental Health: Back in July, EPIC highlighted the mental health issue in Iraq, noting its high prevalence amongst Iraqis and Iraq’s lack of capacity to sufficiently deal with the issue. The ongoing crisis and its horrific sights are likely to add to the 18.6% of the population already suffering from mental illness. Sadly, only three mental health clinics exist in Iraq to treat those in need, with one location in Sulaymaniyah and one in Baghdad. Several UN agencies and NGOs have provided psychosocial support for those affected by the conflict, particularly women and children. Yet, in spite of the efforts of these organizations, the mental health crisis will only stabilize when violence subsides. When it does, treating millions afflicted with mental illness and psychological scarring will be a tremendous undertaking, requiring psychologists that Iraq may not have.
Water, Sanitation & Hygiene (WASH):
Even before the crisis water resources and infrastructure were a serious concern to the people of Iraq. The Tigris and Euphrates rivers, accounting for 98% of the country’s surface water , are quickly dwindling. The amount of water per capita fell from 5,900 cubic meters in 1977 to 2,400 cubic meters in 2009. This decline is likely to continue with some suggesting that the two rivers would not reach the sea by 2040. ISIS control of the Mosul Dam was a concerning development in the conflict. With the help of US airstrikes, the Kurdish Peshmerga were able to recapture the dam, averting a serious water supply crisis. If the group had kept control of the dam, experts believe they would have done one of two things. The first option, and perhaps the most catastrophic, would be to breach the dam, causing a 35 foot wave to wash away Mosul and reach Baghdad with 15 foot floods. The option, unthinkable, wouldn’t be unlikely. The Dam’s structural deficiencies would have made the job very easy. The group also already used such a tactic in the Anbar province, when ISIS flooded Fallujah Dam earlier in the year. The group’s second course of action would have been to cut off areas downstream of the dam, particularly the predominantly Shia southern governorates. The group has strategically cut off water from areas downstream on many occasions, including interrupted water provision in Telkaif and Hamdaniyah. If used again, the tactic would further threaten food security and leave many Iraqis without key water resources. State of WASH Infrastructure
In addition to this decline in resources, WASH infrastructure is poorly funded and maintained. Water infrastructure in Iraq struggled to recover from the economic stagnation under UN sanctions and damage caused by decades filled with conflicts. While overall WASH programming has improved within the last three decades, surveys depict a country struggling to provide adequate drinking water and sanitation. UNICEF’s Multiple indicator Cluster Survey 2011, indicated that in 27% of households tested there were no traces of chlorine in the water. The crisis has limited access to clean water and sanitation. Severe shortages of chlorine are occurring in areas of conflict, particularly the Ninewa and Anbar governorates. In other areas, mass movements have overwhelmed existing water infrastructure, particularly sanitation facilities. Given the pre-existing low quality of WASH infrastructure, direct damage or increased use have exacerbated ongoing problems in Iraq. Health implications: The 2007 Cholera outbreak, was evidence of severe shortcomings in Iraq’s WASH infrastructure. Cholera is a an acute intestinal infection caused by the consumption of contaminated water or food. The intestinal infection induces watery diarrhea and often vomiting, which can quickly lead to dehydration. With simple use of Chlorine and other water treatment measures Cholera can be avoided. Yet, in 2007 some areas didn’t have chlorine, leading to the outbreak in which at least 24 people died and more than 4,000 cases were diagnosed. The spread of Cholera in 2007 was not an isolated incident. It’s a common news story in Iraq, as the water infrastructure continues to leave millions without clean drinking water. 2008 and 2012 saw similar Cholera outbreaks, as poor water infrastructure persisted. The current conflict has elevated the risk of a similar cholera outbreak. Water infrastructure remains damaged, and access to clean water is limited. Given the hot weather and living conditions of many IDPs, consumption of dirty water is on the rise. Iraqis are at risk of other water borne diseases as well. Gastroenteritis, brucellosis, hepatitis and Typhoid fever are among the other concerning water borne diseases resulting from poor infrastructure.
The current crisis has hampered food production, disrupted distribution, and depleted food supplies within Iraq. While no immediate food shortages are occurring, the long term status of food security is concerning. Fadel El-Zubi, the U.N Food and Agriculture Organization (FAO) representative for Iraq recently said, “Now is the worst time for food insecurity since the sanctions and things are getting worse.” UN sanctions against Iraq increased food deprivation to 15 percent by 1996. In the late 90s, the number rose to nearly one-third of the population. The Oil-for Food programme in 1995, helped relieve the strain of the sanctions, yet it was the Public distribution system that helped provide greater food access to the Iraqi population. Over the past decade, Iraq appears to have made some progress, however food deprivation differed by region and Iraq was still heavily dependent on food imports. (For more see IRIN’s article on food security 10 years after the US invasion) Experts predicted that 2014 would yield favorable crop production in Iraq. Increased rain fall placed wheat harvest predictions at 16% above their five year average. Yet, the conflict uprooted many farmers just as the season’s harvest began. With the Nineveh and Salahaddin governorates contributing to nearly a third of Iraq’s wheat production and 38% of its barley, the recent crisis has disrupted Iraq’s productive capabilities. A recent report indicates that ISIS has seized around 40 percent of Iraq’s wheat and are looting government grain silos. Iraq’s Trade ministry said that 1.1. million tons of wheat is currently being held in silos of ISIS controlled territories, 20 percent of Iraqi people’s annual intake. ISIS currently sells the grain on the black market, and rarely compensate farmers who harvest the grain. For those who can access food, the challenge will be whether they can afford it. Costs of staple commodities are likely to rise given the disruption in production, higher fuel costs, and deterioration of reserves in Nineveh and Salahaddin. With rising food prices and an influx of displaced persons, host communities are increasingly strained, raising tensions among Iraq IDPs and host communities. In addition to the higher prices, the distribution of food is much more difficult. The public distribution system on which many Iraqis rely, is now disrupted. The system supplies subsidized flour and other goods. While many have criticized the system for being corrupt and wasteful, poor Iraqis are dependent upon it. With the recent turmoil, the system no longer functions in areas of conflict.
The Food and Agriculture Organization (FAO), World Food Program (WFP), and its Food Security Cluster have taken leading roles in the response. The World Food Programme and its partners have establihsed field kitchens in Dohuk, helping to feed over 100,000 people per day. For the time being, these groups have been able to address food insecurity in accessible areas. Unfortunately many Iraqis are not receiving food. Inaccessibility to conflict areas and the transient nature of IDPs, have made food distribution difficult. If the humanitarian situation continues, food security will become a big concern as production in Iraq is hampered.
The international response to the crisis has been substantial. Saudi Arabia’s $500 million donation to the UN, US and UK aid drops, and organizations on the ground have gone a long way in addressing the crisis. Yet more work needs to be done. The immensity of the humanitarian crisis and an inability to access certain areas, has left many without important humanitarian support. The UN Strategic Response plan, launched in March, is being rewritten for a third time, reflecting the growing needs of Iraqis in crisis.(You can help by donating to the SRP) While the current conflict will pass, important work will remain to resolve Iraq’s underlying development and humanitarian issues. The United States and International community must make a long term commitment to the people of Iraq and the development of their country. To stay up to date on the humanitarian developments of the Iraq Crisis check out these wonderful resources: