Update- Civilian Health in Baghdad- 2006

The MFP Report, "Civilian Health in Baghdad" released on February 1, 2005 described the deteriorating condition of hospitals in Baghdad. The report brought to light unhygenienic conditions inside and in the vicinity of hospitals which posed a threat to patients and workers, the lack of critical medicine and hospital supplies (e.g. disinfectants and detergents), infrastructure breakdown, particularly the lack of access to potable water and sanitation services, and most important, a diminishing cadre of well-trained Iraqi physicians. The report proposed a number of strategic, low cost interventions to reverse the impending collapse of the Iraqi health care system.

In the past two years, all of the problems cited in the MFP Report have worsened, and hospital security, an area in which the report praised the Iraqi authorities, has taken a dramatic turn for the worse. The precise state of health of the Iraqi civilian population is not known because meaningful health services data and outcomes (e.g. infant mortality rates) are not collected by the Ministry of Health or by the occupying forces. Vaccination data is available and it appears that the MOH has conducted a successful vaccination program for MMR and polio, which is laudable. Never the less, UNICEF in its report, "State of the World's Children-2006" ranked Iraq 157 out of 180 countries in the world with respect to child health and development.

There are three major societal factors which have emerged during the occupation and insurgency which accounts for the critical state of Iraqi civilian health:

· Increased violence and insecurity. Random lawlessness, partisan violence by Shi'ite and Sunni militias, and occupying forces raids have forced many Iraqis to stay in their homes and has caused displacement of large numbers of Iraqis to safer areas within and outside of the country. Patients and health workers are fearful of traveling to hospitals and health clinics. Even hospitals are not safe as bombings have been reported in 2006, not only in the street, but in hospital emergency rooms as well.

The destruction of the towns of Falluja, Samara and Tel Afar by coalition forces has created hundreds of thousands of refugees, many without access to health care. During the siege of Falluja, doctors were prohibited from entering the town, electricity was shut off in the hospital, and the hospital was held under siege.

The most critical factor in the poor standard of health care in Iraq is the flight of physicians out of the country, as was pointed out in the MFP 2005 report. It is now estimated by the Iraq Medical Society that as many as 12,000 of the 34,000 registered physicians have left the country since the American invasion. Physicians have been the target of criminal abductions for money, political assassinations, and repeated threats. The targeting of physicians has deprived Iraq of its most senior and accomplished health care givers and left much of medical care delivery in the hands of more junior physicians.

· Politicalization of the Ministry of Health (MOH). The MOH has been ineffective in organizing a health care system capable of providing minimum standards of care to the Iraqi population. There was a delay of nine weeks after the invasion before the Coalition Provisional Authority (CPA) brought in a health team to run the Ministry of Health. During this period there was a complete disruption of the health care system. The CPA team that was put in place was inept and inexperienced in running a National health program and the MOH floundered during this period. Since that time there has been six different individuals heading the Ministry. In December 2005, the MOH was turned over to individuals in the political faction of Shia cleric, Muqtada al-Sadr. The Ministry is now run by Shia loyalists, many without any experience in medicine or public health. There have been many reports of inequitable distribution of medicine and supplies, with preference to hospitals in Shia areas. The Shia dominated MOH has also changed hospitals from safe-havens to command and control centers for al-Sadr's Mahdi army. There have been numerous reports of Sunni patients being dragged from their hospital beds and subjected to interrogation, torture and assassination. Iraqi's Health Minister Ali al-Shaneri, a follower of al-Sadr, disputes these reports.

· Failure of the reconstruction effort. The health care system is dependent on the country's physical infrastructure which was seriously compromised during the bombing raids of 1991, never completely restored because of the UN sanctions and further damaged during the invasion and insurrection. The Iraqi civilian infrastructure (water, sanitation, electricity) has been the focus of reconstruction efforts. The programs and operations of the US Iraq Relief and Reconstruction Fund (IRRF) has failed to meet most of its objectives due to mismanagement, fraud by American companies, corruption and theft by Iraqi subcontractors, and by unanticipated use of funds for security in the face of an aggressive insurgency. Electrical power averages 4-10 hours per day through most of the country. The current output of; the 3700 megawatts is down from pre-invasion levels. Only 25% of the population now has access to potable water and 20% have access to sewerage removal, also below pre-invasion levels. Oil production, which is used to finance the reconstruction, remains below 2 million barrels per day, well below anticipated output because of corruption, illegal sales and attacks by insurgents on pipelines and relay stations.

In April 2003, USAID awarded ABT Associates, Inc., a US firm, $43 million to improve the MOH and distribute medical supplies. A USAID audit found that medical kits for 600 clinics contained useless or damaged equipment.

The US House Committee on Government Reform held hearings in 2006 on two major IRRF health projects: the construction of Primary Health Centers in Iraq and construction of the Basrah Children's Hospital. Bechtel National Corporation was contracted to build 142 primary care centers in Iraq over the period of two years and completed only 6, at an expenditure of $186 million. The US Army Corps of Engineers is now contracted to finish to project. The hearings indicated a long list of management problems including lack of oversight by the US government and poorly supervised work by contractors. Similar criticism were levied at the Basrah Children's Hospital project which began at cost of $50 million and is now up to $98 million and appears will be built without instillation of any medical equipment. There have been a number of successful reconstruction efforts, including renovation of the 331 bed hospital at Baqubah. The failure for cost-effective use of reconstruction funds for Iraq will continue to be the subject of Congressional hearings.

Data in this report was taken from news reports, reports of non-governmental relief organizations, USAID reports, and observations of colleagues and coworkers in Iraq.

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