Of all the areas of Iraq’s development that were affected by the US-led invasion 10 years ago, healthcare has probably taken the biggest hit.
The impact of the 2003 invasion and subsequent conflict on Iraq’s healthcare system has been well-documented. (Check out consistent coverage of the health consequences of Iraq’s conflict by the Lancet medical journal here.) The conflict shattered Iraq's primary healthcare delivery, disease control and prevention services, and health research infrastructure. Attempts to resurrect Iraq's healthcare system remain hindered by a number of factors, including fragile national security and lack of utilities like water and electricity.
Much of the damage incurred in the first few years of the invasion continues to have an impact today.
Iraq had prioritized healthcare at least since the 1920s, when the Royal College of Medicine was formed to train doctors locally. By the 1970s, Iraq’s health care system was “one of the most advanced” in the region, according to researcher Omar Al-Dewachi, a medical doctor who worked in Iraq during the 1990s before emigrating to the US. Health indicators improved quickly and significantly in the 1970s and 1980s, only to deteriorate again after the first Gulf War of 1991, which destroyed health infrastructure, and during a decade of sanctions, which drastically reduced government spending on health and led to a brain drain in the medical profession.
After the 2003 invasion, the healthcare situation deteriorated considerably, and Mac Skelton, a contributor to the Costs of War project, fears it may never recover. Between 2003 and 2007, half of Iraq’s remaining 18,000 doctors left the country, according to Medact, a British-based global health charity. Few intend to return.
“Getting back to that robust, excellent standard [of healthcare] is not going to happen anytime soon,” Skelton told IRIN. “Unlike buildings that can be rebuilt, migration patterns aren’t reversed easily.”
In 2011, according to the World Health Organization (WHO), Iraq had 7.8 doctors per 10,000 people - a rate two, if not three or four times lower, than its neighbours Jordan, Lebanon, Syria and even the Occupied Palestinian Territory. In the Muslim world, Iraq’s doctor-patient ratio is higher only than Afghanistan, Djibouti, Morocco, Somalia, South Sudan and Yemen.
In a recent article in the Lancet, the aid group Médecins sans Frontières (MSF) said that “until now, it is extremely difficult to find Iraqi medical doctors willing to work in certain areas because they fear for their security.”
According to MSF, many remote areas were excluded from state reconstruction and development efforts, “leaving thousands of Iraqis without access to essential healthcare to this day.”
Nearly all families - 96.4 percent - have no health insurance whatsoever and 40 percent of the population deems the quality of healthcare services in their area to be bad or very bad, according to the Iraq Knowledge Network (IKN) survey of 2011.
As a result of the poor quality of care in their country, many Iraqis now seek healthcare abroad, increasingly selling homes, cars and other possessions to afford to do so, according to Skelton, who interviewed Iraqis seeking healthcare in Lebanon.
And researchers are still questioning the degree to which white phosphorus and depleted uranium, the armour-piercing, radio-active metal used in British and American ammunition, has increased cancer rates and caused birth defects.
The environmental damage caused by the war - degradation of forests and wetlands, wildlife destruction, greenhouse gases, air pollution - will also have a longer-term impacts on health, according to the Costs of War project.
A 2007 survey by the government and WHO found that more than one-third of respondents had “significant psychological distress” and presented potential psychiatric cases. A 2009 government mental health survey concluded that mass displacement and a climate of fear, torture, death and violence have contributed to the high ratio of mental illness in the country.
In a new report released last month, MSF said mental health continues to be a major problem in the country.
“Many Iraqis have been pushed to their absolute limit as decades of conflict and instability has wreaked devastation,” Helen O’Neill, MSF’s head of mission in Iraq, said in a statement.
“Mentally exhausted by their experiences, many struggle to understand what is happening to them. The feelings of isolation and hopelessness are compounded by the taboo associated with mental health issues and the lack of mental healthcare services that people can turn to for help.”
The statistics, as always in Iraq, tell a story that is less clear-cut.
The number of fully immunized children, for example, dropped from 60.7 percent in 2000 to 38.5 percent in 2006, then rose to 46.5 percent by 2011 - still less than pre-invasion levels, according to the Multiple Indicator Cluster Surveys (MICS) conducted by the government and the UN Children’s Fund (UNICEF). Acute and chronic malnutrition trends for children under five also showed a slight regression.
However, other indicators show some improvement over pre-2003 levels - unsurprising, some say, if you consider the “semi-starvation diet” of many Iraqis during the sanctions.
According to the UN’s Human Development Reports, life expectancy at birth rose from 58.7 before 2000 to 69.6 in 2012. (These figures are quite similar to those of WHO, but differ significantly from those of the World Bank, which show a regression from 70 to 71 years during the mid-1990s and early 2000s, to 69 years in 2011)
The last decade undoubtedly saw a great reduction in infant mortality rates, not only over pre-invasion levels, but even compared to the early 1980s, when about 80 infants died per 1,000 live births. By the year 1990, this figure was down to 50, and decreased further to 31.9 in 2011, according to a 2012 government report monitoring progress towards the Millennium Development Goals (MDGs).
Still, this rate remains more than double the national target of 17 per 1,000 by 2015; and while Iraq’s rate in the early 1980s was among the best compared to other countries in the region, today, it is among the worst.
The mortality rate of children under five also dropped from 42.8 per 1,000 births in 2000 to 37.2 in 2011, well ahead of 1960s levels, but far off the national target of 21 by 2015, according to the government report, which monitored MDG indicators at the governorate level. The percentage of births attended by skilled personnel also rose from 72.1 percent in 2000 to 90.9 percent in 2011, according to the MICS.
(WHO shows a similar trend of decrease in mortality rates, but its statistics are quite different, showing a much larger drop in infant mortality from 108 deaths per 1,000 in 1999 to 21 per 1,000 in 2011, and a decrease in child mortality from 131 in 1999 to 25 in 2011.)
Government expenditures on health have increased in the last decade. From a high point in 1980s, they dropped significantly due to the 1991 Gulf war and sanctions. But spending jumped from 2.7 percent of GDP in 2003 to 8.4 percent in 2010, according to the World Bank. According to Yasseen Ahmed Abbas, head of the Iraqi Red Crescent Society, government allocations for health spending have risen from $30 million a year under former president Saddam Hussein to $6 billion a year today.
For other development indicators, visit IRIN's series: Iraq 10 years on.