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Epidemiology and Risk: Health Effects of War and Sanctions on the Population of Iraq

Risk has multiple meanings and personal cognitive interpretations. To risk is to endanger, expose to the chance of injury or loss, to incur risk or danger. Risk is the probability an event will occur. Each act or non-act in one's life carries a certain degree of risk; risk is an inherent aspect of being alive. In contemporary American society, risk has become a very loaded word, causing American citizens to experience an unnecessarily high level of stress and fear.

While a perception of risk has been factoring into various trivialities, such as catching a cold or riding a bike without a helmet, the risks associated with war are a terribly important reality that is kept out of the general consciousness of Americans. They see more on the news concerning the sexual harassment lawsuits of athletes than images of innocent civilian bombing victims, and they perceive even less so the social consequences of war and sanctions.

The factors affecting perception of risk in Iraq may be divided into two categories. The first, awareness, is a relationship between the perceived rate of incidence of a health issue as a function of perception and the actual level of occurrence. Citizens in a region at war are more aware of problems such as cancer, and are likely to correlate them with war-related ideas (a placebo effect). For instance, the idea that depleted uranium has caused an increase in the rate of cancer and birth defects in Iraqi civilians and U.S. soldiers, claimed by many, has been disproved in many studies.1, 2 However, there are also studies and first-hand accounts indicating that there has been an increased rate of certain cancers, birth defects, and respiratory diseases resulting from the chemical, not radiological, toxicity of depleted uranium. 3

Americans will most likely perceive the health risks of Iraqi's based on their political orientation: those who identify themselves as 'anti-war' perceive greater risk to support their viewpoint, those who identify themselves otherwise perceive less risk, probably as a means to protect the psychological comfort that the stasis of their respective consensus reality and ideological system. The second category, propaganda, underlies the fact that the authorities, the power-holders, will manipulate data and media for political advantage. While Iraqi reports may have overestimated excess deaths resulting from sanctions, the U.S. government makes every effort to either deny civilian casualties or dismiss their importance.4

Power, economics, national idealism and ideological identification are some of the main causal agents of war. American society, (not limited to but primarily the preponderance of elements exercising disproportionate amounts of power and influence such as the government and media), has infused a collective sense of fear amongst its citizens of acts of terrorism, terrorists, and their respective nations and religions. Structuralist theory contends that authority and trust is allocated to an authority figure; i.e., the authority and trust surrendered to the U.S. government by its citizens allows it to pursue interests only tenuously related to the good of the governed. The risk of an internal terrorist attack by a non-U.S. citizen is very low. There have only been two such incidents since Pearl Harbor, both at the World Trade Center. Un-humanistic though it may be, a quantitative view of casualties or 'victims' of such attacks reveals an alarming disparity: do the deaths of several thousand Americans justify and authorize the deaths of the million or so Iraqis who have died unnecessarily as a result of war and sanctions?

In a political economic analysis, a false perceived sense of risk in the US population allows its government to pursue imperial interests (geopolitical positioning) and economic interests (oil and trade). Two wars and international have sanctions have directly caused many problems, primarily health related, for Iraqi citizens. For Iraqis who were not part of Saddam Hussein's elite, poverty, power, and global politics have proven to be the primary determinants of health.

Led by the U.S., the U.N. imposed severe sanctions on Iraq with the aim of compliance with weapons inspectors and the removal of their leader from power. Unfortunately these sanctions primarily affected the citizens of Iraq, whose economic and social rights were seriously disrupted by the embargo. The dictatorship continued its strong control while the burden of economic hardship fell on the civilians. Denis Halliday, the former co-ordinator of humanitarian relief to Iraq and ex-Assistant Secretary-General of the United Nations, said:

I had been instructed to implement a policy that satisfies the definition of genocide: a deliberate policy that has effectively killed well over a million individuals, children and adults. We all know that the regime, Saddam Hussein, is not paying the price for economic sanctions; on the contrary, he has been strengthened by them.5

There were many effects of the wars and U.N. sanctions against Iraq. Civilian casualties have resulted from bombing campaigns conducted both during and between wars, internal terrorist activities, and unexploded ordnances that UNICEF says kill or injure a child every day.6 Great internal damage was done:

The bombing devastated Iraq's civilian infrastructure, destroying eighteen of twenty electricity-generating plants and disabling vital water-pumping and sanitation systems. Untreated sewage flowed into rivers used for drinking water, resulting in a rapid spread of infectious disease. Comprehensive trade sanctions compounded the effects of the war, making it difficult to rebuild, and adding new horrors of hunger and malnutrition. 7

Sanctions would not allow Iraq to import chlorine to purify water, nor allow importation of parts needed to repair damaged purification plants. This put roughly 800,000 people in Southern Iraq at risk from water borne diseases.8 With less money available, the citizens who had previously imported most food-stuffs began to grow some staple items, often with ill consequences from infectious disease.

A contaminated and insufficient water supply resulted, partly a result of sewage buildup, resulting in greater rates of infectious diseases, dehydration, diarrhea, and malnutrition. With the sanctions still in effect, most irrigation and drainage programmes in Iraq have suffered…rice production, leading to water stagnation in irrigated fields near human habitation, has led to extremely high prevalence of malaria, caused by high levels of vector breeding of the A. sacharovi and A. stephensi stephensi mosquitoes. This has caused another serious public health problem, triggered by the scarcity of appropriate drugs for treatment and insecticides for vector control.

The reduction in the import of medicines, owing to a lack of financial resources, as well as a lack of minimum health care facilities…have crippled the health care services, which in pre-war years were of a high quality. Assessment reports rightly remarked that the quality of health care in Iraq, due to the six-week 1991 war and the subsequent sanctions imposed on the country, has been literally put back by at least 50 years. Diseases such as malaria, typhoid and cholera, which were once almost under control, have rebounded since 1991 at epidemic levels, with the health sector as a helpless witness. 9

Vaccination efforts were disrupted:

The National Immunization Programme which had begun in 1985 came to a complete halt between January and April 1991. The percentage of fully immunised one year old children fell from 94 for tuberculosis, 83 for diptheria, tetanus, and pertussis, 83 for polio, and 82 for measles to 79, 63, 64, and 68 respectively.10

Disease levels rose due to shortages of critical medical supplies and basic infrastructure deterioration. Many cases of disease could be treated, but the drug shortage in Iraq makes successful treatment nearly impossible. A UN investigative mission found that in 1994, 2,380 children died of diarrhea as compared with 121 in 1989 and 1789 of pneumonia, as compared with 139 in 1989.11 Re-emerging diseases also became much more prolific.

Diarrheal diseases and mortality due to dehydration were well under control prior to the Gulf War; there was a threefold increase from May 1990 to May 1991. Other water born infections increased from 1990 to 1999, for example typhoid by 60% and cholera almost fivefold. A measles epidemic occurred in 1998.There have been alarming rises in cases of malaria and leishmaniasis. Other infections like tetanus, poliomyelitis, diphtheria, and pertussis all showed an increase after the Gulf War. 108

Iraqui children in 2004. UNICEF estimated that "half a million Iraqi children died between 1991 and 1998 who would have lived if pre-sanctions trends of declining mortality had continued. How many more have died from 1998 to 2004?

A UNICEF report stated that after the 1991 Gulf war, child malnutrition in Iraq rose sharply.12 It cites many reasons, including destruction of infrastructure, international sanctions, and poor use of resources. Sanctions were criticized for decreasing the purchasing power of families and therefore also decreasing their protein consumption, causing Iraqi women to suffer from iron deficiency, and causing children to be underweight at birth.

While many children suffered from various degrees of malnutrition, they did not typically die from hunger. Carel De Rooy, the UNICEF representative in Iraq, stated that "In this situation, when children are weak, diarrhea caused by bad water will kill…(t)ens of thousands of children are extremely vulnerable to any further deterioration in their health and nutrition status."13 Safe drinking water is a problem all across Iraq - between 1990 to 1996 the cases of diarrhea have increased from about 3.8 episodes per child/year to nearly 15.14 Even a short war can have drastic effects, as is evident from the 2003 invasion of Iraq by the U.S.

A rapid post-war nutritional assessment carried out by UNICEF in Baghdad found that acute malnutrition or wasting, measured by a child's weight for height, has nearly doubled from four per cent a year ago, to almost eight per cent. Wasting in children is related not only to how much they have to eat, but to their body's ability to retain what is eaten. The rapid assessment also revealed that seven out of 10 children suffered from various degrees of diarrhea. Diarrhea leads to the loss of nutrients in the body, to dehydration and all too often to death when not properly treated. 15

One of the greatest effects of war and sanctions in Iraq is an increase in infant and child mortality rates. UNICEF recently reported that infant mortality and under-5 mortality rates have risen from 47 (IMR) and from 56 (Under 5 MR) in the period 1984-1989, to 108 and 131 respectively for the period 1994-1999.16 In a comparison of these mortality rates with pre-1990 trends of declining child mortality in Iraq, UNICEF estimated that "half a million Iraqi children died between 1991 and 1998 who would have lived if pre-sanctions trends of declining mortality had continued." 17

Sustained increases of infant mortality rates were very rare in the 20th century.18 In Iraq, a mortality rate of under five-year-olds greater than 80 per 1,000 births has not been experienced since about 1980.19 Richard Garfield of Columbia University wrote,

Living conditions in Iraq, thus, represent a loss of several decades of progress in reducing mortality. This is a social disaster which should be urgently addressed. To the degree that economic sanctions complicate access to and utilization of essential goods, sanctions and regulations should be modified immediately. 20

Studies have shown that in countries against which broad economic sanctions are applied, malnutrition caused by the high cost and shortage of food is often a leading cause of morbidity and death among children.

In four hospitals in [Iraq], infant malnutrition was reported to affect between 32% and 57% of hospitalized children. Infant malnutrition was compounded by the unavailability of infant formula and the malnutrition of breast-feeding mothers. In addition, many deaths resulted from an increased incidence of waterborne diseases, including cholera, typhoid, and gastroenteritis, that were caused by contaminated water and defective sewage systems.21

The litany of political, economic, social, and health problems that have persisted since the 1991 Gulf War created a humanitarian disaster for the people of Iraq. The cause of these deaths is very simple - "economic collapse with plummeting wages, soaring food prices, poor sanitation, lack of safe water, and inadequate provision of health care."23 The cumulative effects of two wars and severe sanctions debilitated social services, reflected in the infant mortality rates which rose from 47 deaths per 1000 live births between 1984-1989 to 79 between 1989-1994, and to 108 between 1994-1999.22 Saddam Hussein was largely unaffected, and used these circumstances to his political advantage.

How does a nation and a global community consider, decide, and act upon an appropriate course of restorative action in light of such a daunting public health dilemma? Should similar measures, sanction and war, be used in the future in response to similar situations? Factors and perceptions of risk must inevitably play a large role in how this question will be answered, if it is to be answered at all. While there were reports that the authoritarian regime of Iraq was committing mass murders, the former Assistant Secretary-General of the United Nations resigned because he viewed the international sanctions as a form of genocide. Another risk factor was that of nuclear weapons: U.S. political leaders misappropriated logic to defend a policy of actualized murder to prevent murder based on risk alone. Now it has been shown that the 2003 war against Iraq was unjustified because there were no weapons of mass destruction found in Iraq. Thousands have been killed in the last year, and international political treaties were destroyed by the nascent U.S. policy of pre-emptive war.

Statistics on increased rates of malnutrition, diarrhea, infectious and re-emerging diseases, and mortality rates indicate the dire situation of the citizens of Iraq whose health risks were greatly increased due to global power and politics. While the proximal causes of death of Iraqi children may be diarrhea, malaria, malnutrition, or cluster bombs, the macroparasitic factors of social class, poverty, power, and politics cannot be ignored.

Table 1. Excess deaths (deaths in excess of the lowest annual rate [1990] during this time period) among Iraqi children per year since the Gulf war and sanctions*

Reprinted from Morbidity and Mortality Among Iraqi Children From 1990 to 1998: Assessing the Impact of Economic Sanctions, by Richard Garfield.

*Citing information on maternal and child mortality rates collected by UNICEF, Professor Richard Garfield estimates that between 1991 and 2002, the number of excess deaths in Iraq among children under age 5 is 343,900 to 525,400.24

Works Cited:

1. McDiarmid, MA. Depleted uranium and public health. [Editorial] BMJ. 322(7279):123-4, 2001 Jan 20.

2. Gulf War syndrome update. (Service). VFW Magazine, August 2003 v90 i11 p12(2)

3. www.who.int/entity/heca/advocacy/ publications/en/HECANETJULYfinal.pdf

4. http://www.alternet.org/story/11933

5. http://www.globalissues.org/Geopolitics/MiddleEast/Iraq/Sanctions.asp

6. http://www.unicef.org/infobycountry/iraq.html

7. http://www.alternet.org/story/11933

8. Ascherio A et al. Effect of the Gulf War on infant and child mortality in Iraq. New England journal of medicine, 1992, 327 (13):931&endash;6.

9. http://www.who.int/disasters/resource/pubs/000396.html

10. http://www.alternet.org/story/11933

11. http://www.au.af.mil/au/awc/awcgate/awc/97-144.pdf

12. http://www.unicef.org/media/media_7601.htm

13. Ibid.

14. http://www.unicef.org/emerg/iraq/index_bigpicture.html

15. http://www.unicef.org/infobycountry/iraq.html

16. Child and Maternal Mortality Survey, UNICEF 1999

17. http://www.globalissues.org/Geopolitics/MiddleEast/Iraq/Sanctions.asp

18. Murray, C.J.L., L.C. Chen. "In Search Of a Contemporary Theory for Understanding Mortality Change." Social Science and Medicine 1993: 36; 143-55.

19. UN. Mortality of Children under Age Five, World Estimates and Projections, 1950- 2025. New York: Population Studies # 105.

20. http://www.casi.org.uk/info/garfield/dr-garfield.html 

21. Karine Morin, LLM and Steven H. Miles, MD. The Health Effects of Economic Sanctions and Embargoes: The Role of Health Professionals. Annals of Internal Medicine: 18 January 2000; 132,2: 158-161.

22. http://www.unicef.org/evaldatabase/index_14461.htm

23. Dobson R. Sanctions against Iraq "double" child mortality. BMJ 2001;321:1490.

24. http://www.pbs.org/frontlineworld/stories/iraq/sanctions.html

Copyright 2004 West Art, Prometheus 94/2004

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Copyright 2004 West-Art

PROMETHEUS, Internet Bulletin for Art, News, Politics and Science.

Nr. 94, Winter 2005