2008; 371:177(January 19, 2008)
Morbidity and mortality among families in Iraq
Read also the below mentioned reports per
and Rehabilitation under Fire
How unfortunate that comment on the Iraq Family Health Survey (IFHS) Report, released by WHO on Jan 9, has sparked such a heated and distracting debate on estimates of civilian mortality. The shocking figure of 151 000 violent deaths between March, 2003, and June, 2006, is of the same order of magnitude as a previous figure and serves to confirm that far too many civilians have been killed during the US-led occupation. The sooner this fact is accepted, the sooner the crucial issue of rebuilding the shattered lives that lie behind such numbers can begin.
The survey, of Iraqis, by Iraqis, and for Iraqis, shows the consequences of years of repression, sanctions, and conflict on the health of over 9000 representative households. Not only does the report provide a moving account of hardship, especially for Iraqi women, but the findings will inform planning for future health-care programmes tailored to the needs of the Iraqi people, rather than the imposed wants of external contractors.
The absence of reliable health metrics has hampered efforts to define the most appropriate health service for Iraq's population. The IFHS begins to fill this need with credible information on demographics, public health, chronic illnesses, and acute services. Iraq is a young country, half of whose population is under 20 years of age. Whereas mental ill-health generally tends to represent about 11% of morbidity, over a third of respondents had considerable psychological distress; women were particularly vulnerable.
A quarter of Iraqi women have no formal education and only 10% complete secondary school by contrast with 16% of men. Almost half of women are unaware of HIV/AIDS. Average parity is 3·6. Although most women are delivered by skilled attendants, the maternal mortality ratio has risen since 2003, from 47 to 84 per 100 000 livebirths. The IFHS is the first systematic measure of domestic violence in Iraq. The report found that 83% of women complained of controlling behaviour by their husbands (such as needing permission to attend a health facility), over a third had experienced emotional cruelty, and more than a fifth suffered physical violence.
In the 30 days before the survey, average household expenditure on health was US$46 (13% of monthly household expenses). 30% of households had to borrow money for medical bills, and this proportion approached 50% when a member of the household was hospitalised.
A separate report, Rehabilitation under fire, released on Jan 16 by the UK charity, Medact, outlines the dissolution of the Iraqi health-care system that has led to the current chaos. Little attention has been paid to the health-care infrastructure since the first Gulf war in 1991. Although the Pentagon was warned about the vulnerability and importance of health facilities before the second war in 2003, 7% of health-care buildings were damaged in the invasion, 12% were looted, and many health personnel were kidnapped. In the years that followed, the Iraq Medical Association estimates that half of the country's 34 000 doctors have fled (along with 2·2 million other Iraqis), 2000 doctors have been killed, and others will be among the 2·4 million internally displaced citizens. As a result, as few as 9000 doctors and 15 000 nurses remain to look after a population of 28 million people.
Incredibly, only 4% of the $18·4 billion reconstruction budget has gone to health-care projects, with contracts favouring profit-driven private companies, rather than international agencies specialising in health care. The emphasis, as Frederick Burkle, the first Interim Minister of Health for Iraq points out in his Comment in today's Lancet, has been on visible short-term achievements, rather than sustainable long-term health gains. For example, an attempt was made to rewrite Iraq's national formulary, not along WHO guidelines, which are used by 80% of countries, but to favour European and US suppliers. The result of such intrusions is a fragmented system that women cannot readily access, that households cannot afford, and that is unfit for the purpose of restoring essential public-health services.
Disturbingly, the IFHS indicates that the violence and insecurity endemic in Iraq is now reflected by violence and anxiety within households. Although a thoroughly renovated health-care system is required urgently to address the consequences of these behaviours, such a system cannot succeed without parallel improvements in security and the confidence of exiled health workers to return. Without an accessible and effective health system, in which returning health professionals can practise in safety, the coalition's legacy of civilian morbidity will be even greater than its shameful record of civilian mortality.