Iraqi healthcare system still crippled five years after invasion, says report

Iraq’s health system is still crippled, nearly five years after the US led invasion of 2003, partly as a result of a disorganised and often incompetent reconstruction effort, concludes a new report from campaigning organisation Medact.

The report describes Iraq as “a failing state with a complex health emergency,” with as few as 9000 doctors and 15 000 nurses serving a population of 28 million people. Around half of Iraq’s doctors have fled the country, while many more are counted among the 2.2 million internal refugees.

The report follows the publication last week in the New England Journal of Medicine (doi: 10.1056/NEJMsa0707782) of the largest household survey to date, measuring mortality in Iraq after the invasion . The Iraq family health survey, led by the World Health Organization, found sharp rises in all cause mortality as well as a heavy death toll from violence.

It estimates that 151 000 Iraqis died from violence between March 2003 and June 2006, most of them men. Violence was the leading cause of death in men aged 15 to 59.

The findings are based on 9345 households in 971 clusters, a sample almost 10 times larger than in the most recent survey, published in the Lancet in October 2006 (368;1421-8), which estimated 601 000 excess deaths from violence.

The latest survey shows a steep rise in all cause mortality, even in groups less affected by violence. Among children under 15, all cause mortality rose from 2.82 deaths per 1000 person years before the invasion to 4.37 in 2003-6. Of this 1.55 increase, only 0.34 deaths per 1000 person years were attributable to violence. The remaining 1.21 non-violent deaths per 1000 person years translate into around 45 000 excess deaths in this age group.

Mohammed Ali of the World Health Organization, one of the Iraq family health survey researchers, said the results showed that overall non-violent mortality increased 60% after the invasion. “We’re planning to do further work on those numbers,” he told the BMJ.

Early hopes for a modernised Iraqi health system were swiftly dispelled by the collapse in security, said health consultant Jane Salvage, a visiting professor at King’s College London and one of the authors of the Medact report.

“But even though we all know how difficult reconstruction in post conflict situations is―much less active conflict―it’s clear that international best practice was often not followed,” she said.

Political agendas have tainted almost all health decisions, the report argues, citing an American attempt to change Iraq’s drug formulary to one that would require more purchasing from the United States. After a year of confusion the new health minister, Aladin Alwan, cancelled the revisions and encouraged local production instead. “We didn’t need a new formulary,” he said. “We needed drugs.”