Potential impact of conflict on health in Iraq
Briefing note: March 2003
Health situation in Iraq
The people of Iraq face a mixture of health hazards associated with poverty. Children, adolescents, women, the elderly, disabled people and those who are chronically ill are at particular risk. Insufficient food intake endangers the nutritional status of a large part of the population, though nutritional status of the majority of the population has improved following the inception of the OFFP. Child malnutrition rates are reportedly high. Communicable diseases are a major cause of illness and death. Non-communicable illnesses due to cardiovascular diseases, cancer and diabetes, constitute a rising health burden.
Box 2: Basic health indicators for Iraq
In 2001, life expectancy at birth was reported to be 58.7 years for men and 62.9 years for women. The infant mortality rate for 2000/2001 was estimated at 98 per 1000 live births. The mortality rate for children under the age of five was estimated for 2001 to be 133 per 1000 live births. Maternal mortality in 2001 was estimated at 291 per 100 000 live births.
Sources: WHO, UNICEF
The primary causes of the high burden of communicable disease among children are acute lower respiratory infections, diarrhoeal diseases and measles. (see Children's health).
Lack of adequate sanitation and clean drinking water lead to a high risk of diarrhoea outbreaks (see Water and sanitation).
Tuberculosis rates have risen in the last decade. The number of new cases of tuberculosis nearly tripled from 46.1 per 100 000 people in 1989 to an estimated 131.6 per 100 000 people in 2000. One cause is the interruption in supply of anti-TB medicines used for Directly Observed Treatment (DOTS). The supply of anti-TB medicines has improved through the OFFP.
A serious malaria outbreak occurred with a peak of about 100 000 cases per year in 1994 and 1995. This epidemic was caused by the vivax strain of the malaria parasite, which is rarely life-threatening. The outbreak has been attributed to movement of people from endemic into malaria-free zones, delays in access to effective treatment and a lack of effective control measures. Vector control programmes (indoor residual spraying to break the transmission cycle, distribution of insecticide-treated nets) have now led to a decline in malaria incidence to pre-1991 levels. Noncommunicable illnesses
Statistics from the Ministry of Health indicate that cardiovascular diseases – predominantly coronary heart disease and stroke - are the leading cause of death.
Cancer is increasingly seen as a major health problem – in line with the general trend in the region. The main risk factors for cancer-related mortality in the region are assessed as increasing tobacco use and changes in lifestyle, particularly diet. Iraq established a population-based cancer registry in 1976 (one of the first in the region): it is now computerized. As the quality of data obtained through this registry improves, more precise information on cancer trends will become available.
Box 3: Cancer cases reported in Iraq in 2000
In 2000, there were a total of 195 374 new cases of cancer (except skin) in both sexes and 126 677 deaths. Lung cancer was the most common cancer in males and in females the most common cancer was that of the breast.
Source: Globocan 2000 statistics.
The current prevalence of diabetes is unknown, but there are indications that diabetes is a large-scale problem in the Iraqi population. In the year 2000, at least 600 000 of Iraq’s people were estimated to have diabetes: close to 3.0% of the population.
The prognosis of people with chronic illnesses is affected by their levels of nutrition and income, availability of essential medicines and medical equipment, and access to properly staffed medical services.
Food security and nutrition
Estimates suggest that 18 million out of a population of 24.5 million people in Iraq lack secure access to food. Currently, almost 60% of the population is solely dependent on food distributed by the government each month. Food made available in 2002 included wheat flour, rice, sugar, tea, cooking oil, milk powder, dried whole milk and/or cheese, fortified weaning cereal, pulses (beans, chickpeas and lentils), and iodized salt, together with soap and detergent. In July 2002, the daily ration provided through OFFP was raised to 2215 kilocalories per day (see Children's health).
Almost half of Iraq's total population of 24.5 million are children. UN agencies estimate that one out of eight children dies before the age of five; one-third of Iraqi children are malnourished; one-quarter are born underweight and one-quarter do not have access to safe water.
In a recent ranking of estimated mortality rates of children under five years in 195 countries and territories, undertaken by the UN Children’s Fund, only 32 countries had rates higher than those for Iraq.
Box 4: Major causes of death in children in Iraq
The three major killers in children are acute lower respiratory infections, such as pneumonia; diarrhoeal diseases; and measles. Child death rates due to acute lower respiratory infections and diarrhoea have increased over the last decade. These conditions account for 70% of deaths in children under five years of age.
Source: WHO Communicable Disease Profile for Iraq, March 2003.
Between 1991 and 2002, acute malnutrition rates (low weight for height) among children under the age of five in southern and central Iraq rose to 11.0% in 1996 and then fell to 4.0% in 2002 . Rates for stunting (low height for age, reflecting chronic malnutrition) peaked in 1996 at 32.0%, and then declined to 23.1% in 2002.
In the three northern governorates between 1996 and 2002, there was a 20% reduction in acute malnutrition, a 56% reduction in chronic malnutrition and a 44% reduction in the incidence of underweight children in the under-five age group.
However, levels of chronic and acute malnutrition in children are higher now than they were in 1991. Close to one million children under the age of five suffer from chronic malnutrition, often due to a combination of dietary factors and infection – particularly diarrhoea.
An assessment undertaken by UN agencies (Food and Agriculture Organization, World Food Programme and WHO) in 2000 revealed a high prevalence of anaemia in school children. Children with signs of clinical malnutrition - marasmus and kwashiorkor (swelling of limbs and body) – were observed in hospital paediatric wards. Numerous cases of rickets (vitamin D deficiency) were also reported. Reports provided by the Iraqi Ministry of Health in 2001 documented 31 545 cases of kwashiorkor, 291 587 cases of marasmus and 1 977 454 cases of other protein, calorie and vitamin malnutrition in children under five years.
Pertussis (whooping cough) incidence is reported to be on the increase. Cases of diphtheria have also been reported.
Iraq suffered a major outbreak of polio in 1999, but – as a result of intensive immunization efforts - there have been no cases since January 2000. Health workers vaccinated more than four million Iraqi children against polio in February 2003.
Measles immunization rates in children under five over the last few years were: 79% (1998), 96% (2000), 78% (2001) and 96% (2002). The earlier lower rates resulted from vaccine shortages. Indeed, many older children (age 6-12) were not vaccinated in the mid-1990s when vaccines were in short supply. As a consequence, more than two-thirds of measles cases in southern Iraq are occurring in older children. Measles mortality is higher in children suffering from malnutrition.
Ill health associated with pregnancy and deaths associated with childbirth have increased. As mentioned above, the maternal mortality estimate for 2001 was 291 per 100 000 live births.
Recent data on the nutritional status of pregnant women are not available. In 2000, 24.3% of newborns registered had a body-weight of less than 2.5 kg, according to the Iraqi Ministry of Health. In 1990, 4.5% of registered newborns were under 2.5 kg.
Between 1995 and 2001, ante-natal care coverage (the percentage of women aged 15-49 who were attended at least once during pregnancy by skilled health personnel) was 78%. In 1997, 83% of deliveries were attended by trained personnel.
Health services, facilities and personnel
Many essential public health services - such as blood transfusion and water quality control services – are not functioning optimally due to shortages of laboratory reagents. Emergency and ambulance services are sometimes unable to function due to inadequate equipment and supplies. The physical condition of some health facilities has deteriorated: several lack running water and constant electricity supplies.
The Government of Iraq reports that in 1999 there were 1447 medical facilities throughout the country, including 160 hospitals (both general hospitals and specialized centres). In addition, there are 1285 health centres, some of which are not staffed by doctors. WHO data indicate a total number of 26 961 hospital beds.
Medicine and medical supplies
Significant quantities of medicine and medical supplies and equipment have reached Iraq under the OFFP. Together with other supplies being provided, these should be enough to meet the needs of the population for three months. However, if the logistics systems for medicine and supply distribution are disturbed, areas of shortage will develop. Hence the need for stocks of “emergency medicines” in the event of renewed conflict.
Water and sanitation
The operation of water and sanitation plants, many of which were destroyed during the Gulf War, continues to be affected by the lack of spare parts and maintenance. The result is that drinking water is often unsafe. Unhygienic environments and poor sewage systems continue to pose risks to people’s health.
One consequence is frequent outbreaks of diarrhoeal diseases especially during the summer months. Cholera became endemic in all governorates of Iraq after the Gulf War. Cholera outbreaks have been reported, the most recent in June-August 2002.
According to the Water Supply and Sanitation Assessment issued jointly by WHO and UNICEF, about 85% of the population in Iraq had access to water supply services (96% in urban areas and 48% in rural areas) in 2000. About 79% of the population had access to sanitation (a flushing toilet discharging into a public sewer system or a hygienic latrine). However, only 31% of the rural population had access to such sanitation facilites.
Box 5: Access to safe drinking water and sanitation in Iraq
In 2000, about 3.5 million people did not have access to safe drinking water and more than 4.8 million people did not have access to any type of sanitation facility.
Sources: WHO and UNICEF.
There are reports of increased rates of cancers, congenital malformations and renal diseases among the population of Iraq. The Iraqi government has attributed this increase to exposure to depleted uranium (DU). Epidemiological studies are needed to investigate such increases and explore all possible causal factors. Iraqi health officials and scientists, working with WHO, have developed plans for the surveillance of cancers, congenital malformations and renal diseases, for investigating the health effects of environmental risk factors including depleted uranium, and for improved cancer control. The plans have yet to be implemented.
1) Data from a UNICEF-supported household survey conducted by the Iraqi Ministry of Health and the Central Statistical Organization in February 2002.