Tomasz Pierscionek The Lancet, Student 10/13/08

During the 1970s, subsequent to the oil industry being nationalized, a centralised system of healthcare was established in Iraq (1). This government subsidised system was based upon a Western model. It enabled the entire Iraqi population to access free healthcare (1). The country’s immense oil reserves were used to pay for medication and medical equipment, as well as for foreign healthcare workers (1). It is reported that before 1990, despite a severe curtailment of civil liberties, 97% of Iraq’s urban dwellers and 71% of the rural population had access to primary healthcare (1).

The fate of healthcare in Iraq began to change in August 1990 with the outbreak of the first Gulf war (1). Furthermore, the UN Security Council took the decision to implement economic sanctions against the country, on the grounds that these sanctions would weaken Saddam Hussein’s grip on power (2). Within a period of six weeks, the US and its allies had dropped an estimated 88,000 tonnes of bombs, the equivalent of seven Hiroshima explosions, on Iraq (2). Water and sewage treatment plants, which had been damaged in the bombing, were no longer functioning at their optimal capacity (2). Cholera, typhoid and other water-borne diseases became rife (2). The economic sanctions that followed the war resulted in the impoverishment of Iraq and led to a downward spiral in the nation’s health (1).

Chronic shortages of food and medicine became commonplace (2). By 1997, an estimated one million children below the age of five were malnourished (3). Furthermore, as part of the sanctions imposed upon the country, an ‘intellectual boycott’ led to Iraqi doctors being cut off from medical and scientific developments happening around the world (2). This boycott prevented Iraqi doctors accessing the latest literature and restricted them having contact with their counterparts around the world (2).

A decade later, the mortality rate amongst children under the age of five had risen from 56/1000 live births in 1989 to 131/1000 (1). A large increase in the incidence of childhood cancers, widely believed to have been the consequence of depleted uranium shells being used by coalition forces, became noticeable in the years following the first Gulf war (4). Dr Muhammad Hilal, former chief paediatrician of a hospital in Baghdad, has commented that remission rates for childhood cancer plummeted from 70% in 1990 to around 6 or 7% by the end of the decade (2).

The already crippled healthcare system was to take an even greater battering with the onset of the invasion in 2003. In the initial stages of the war, 7% of the nation’s hospitals sustained damage and 12% experienced looting (5,6). The steady exodus of Iraqi health professionals, taking place throughout the 1990s, escalated (6). As the invasion took place without a UN mandate, it was not possible to effectively harness the knowledge of those individuals with expertise in post conflict health planning (6). In Iraq itself, numerous health experts, who were members of the Iraqi Ba’ath party, were dismissed from their jobs as part of the US determined process of ‘de-Baathification’ (6). Furthermore, in contrary to what is prescribed by the Geneva Convention (IV, article 18), hospitals received inadequate protection by the occupying forces (6). In 2004, there were even reports of humanitarian convoys being denied access to the besieged city of Fallujah, by the US and Iraqi army (7). The larger reconstruction contracts were bequeathed to private companies, rather than being placed in the hands of the WHO or UNICEF (6). There is a risk that involving private companies in the reconstruction effort may lead to an emphasis on profit-making and a consequent detraction from humanitarian needs. Iraqi communities were largely excluded from decision making and planning in matters of healthcare provision (6). A rapid succession of health ministers since 2003, has further intensified the instability (6). Meanwhile, the training of health professions has suffered as medical schools are struggling to remain open. A 2008 report, released by the British NGO Medact, indicated that 5 years after the invasion, Iraq [still] has no comprehensive health policy or funding strategy (6).

Since 2003, three-quarters of doctors, nurses and pharmacists have ceased working and half of these have fled the country (6). It has been estimated that only 9000 doctors and 15,000 nurses now remain in Iraq to serve a population of approximately 25 million (6). According to ‘Save the children’, the death rates amongst Iraqi children under five are approaching those of Sub-Saharan Africa (8). In the year 2005, one in eight Iraqi children died before they reached the age of five (8).

One area of healthcare that is currently much needed in Iraq but that has received inadequate funding since 2003, is that of mental health services (6). The mental health effects of the war upon the civilian population are immeasurable and their long-lasting repercussions are as yet unknown. Adult mental health services are limited while children’s mental health services are non-existent (6).

The toll that the war has taken on the physical and mental health of the Iraq people is perhaps particularly severe among the 2 million Iraqis who have received refuge in Syria, Jordan, Egypt or elsewhere in the Middle East (9). They now face the struggle of finding work and accommodation in their new surroundings (9). Syria, with a population of only 18 million has seen its infrastructure struggle to cope with an influx of 1.5 million refugees (10). As the cost of food and fuel has also risen sharply (10), there is evidence that some sections of the Syrian population have started to harbour grudges against the Iraqi refugees (10). Although the Syrian government has taken measures to limit the flow of refugees from Iraq, it has stated that it will not expel any of the refugees who are already in Syria (10).

Although the healthcare situation in Iraq looks bleak, there are steps that can be taken in order to try to resolve the crisis. For example, it is essential that the Iraqi people be at forefront in making decisions about their own healthcare. As recommended in the 2008 Medact report, Iraqi companies should also be given priority over foreign firms when it comes to bidding for healthcare reconstruction projects (6). Additionally, there is a great need for donors to come forward and provide financial aid for humanitarian projects within Iraq (6). The lyrics of US folk singer Pete Seeger’s Vietnam era song ‘Bring em home’ come to mind; they include the words ‘…the world’s got hunger and ignorance… you can’t fight that with guns and bombs.’

Tomasz Pierscionek
Medical Student
Newcastle Medical School, UK


1. UNICEF. Iraq Watching Briefs. Overview Report. Prepared by Sen B. , 2003.

2. Cappacio G. How many must die? Rethinking Schools Online 1999;13(3)

3. UNICEF report. Situation Analysis of Children and Women in Iraq – 1997. Part two: Child survival, rights and basic needs. UNICEF 30th April 1998

4. Al-Azzawi S. Depleted Uranium Radioactive Contamination In Iraq: An Overview. Presented at The 3rd ICBUW International Conference Hiroshima. August 3-6, 2006.

5. Garfield R. Challenges to health service development in Iraq, The Lancet 2003; 362: 1324.

6. MEDACT report. Rehabilitation under fire. Health care in Iraq 2003-2007. London: Medact, 2008.$File/full_report.pdf

7. Ismael S. Fallujah – one year on. Briefing note. Doctors for Iraq, 2005.

8. Save the Children. Saving the lives of children under 5. 8th annual State of the World’s Mothers Report. Connecticut: Save the Children, 2007.

9. UNFPA, UNHCR, UNICEF, WFP, WHO. Health Sector Appeal: Meeting the Health needs of Iraqis Displaced in neighbouring Countries – Joint appeal by UNFPA, UNHCR, UNICEF, WFP and WHO. 18th September 2007.

10. Al-Jazeera news report. Iraqi refugees swell pressure on Syria’s social services. Published on 10th October 2007.