Act now to secure Iraq's health

Abstract

“Before we had security but no freedom. Now we have freedom, but no security. What we need is both.” These are the words of a Baghdad physician quoted in The Lancet's Health and human rights section this week (see p 1324–26), which focuses on medicine in Iraq 6 months after Saddam Hussein's regime was toppled. Reports of the instability that is claiming the lives of Iraqis and coalition forces have been a regular feature in the media since the war ended only to give way to a dangerous power vacuum. The chaos after the official end of hostilities has included widespread looting, social disorder, bombings, and shootings (see p 1288–89). In many areas, hospitals, clinics, laboratories, and health-administration offices have been ransacked. The disruption to essential services, such as water, electricity, police, transport, and communications, has compounded the effect of direct destruction of health facilities. Nevertheless, although Iraq's health infrastructure has been comprehensively destabilised, many of the predicted challenges to health care following the war, such as mass displacement of people and the use of chemical or biological weapons, did not occur. Without doubt, the US Government's plans for health in a post-Saddam Iraq were ill-conceived and have actively delayed and disrupted efforts to restore public services. These impediments largely resulted from the insistence by the US Department of Defense that it control pre-war planning and coordination of relief. UN agencies and local and international non-governmental organisations with experience of working in Iraq were marginalised. This high-handed approach was exemplified after the war by the appointment of James K Haveman to the position of senior advisor to the Iraqi Ministry of Health. The choice of Haveman, a friend of the Bush family with no professional background in post-conflict public health, shocked many, especially since Haveman's overseas experience has been through involvement with a Christian relief organisation. Iraq's health professionals' suspicion of the reconfigured health administration was further deepened by the appointment of Khudair Abbas as Minister of Health; Abbas has been absent from Iraq for 20 years. As one senior Iraqi physician commented to The Lancet, “the people in control of health now are just like the previous regime”, in that Iraq's health professionals are excluded from decision-making and are afraid to speak out and criticise those in power. Despite these obstacles, some progress is being made. On Oct 9, the US House Appropriations Committee voted down a Presidential request for US$150 million towards a new $500-700 million paediatric hospital in Basra. As many public-health experts have pointed out, rural primary care always took second place to advanced city-based care in oil-rich then sanctions-poor Iraq. Thus the concentration of funds on media-friendly tertiary care would only serve to recreate and reinforce this inequity. Instead, the Committee recommended the addition of $100 million to the Presidential request for funds to refurbish and modernise hospitals and primary-care services throughout Iraq. We trust that the House and Senate will support this sensible redistribution of funding for health. Such a commitment to rebuilding and strengthening Iraq's health system would hopefully encourage other countries at the UN Iraq donors' conference scheduled for Madrid on Oct 23-24. The Joint Iraq Needs Assessment prepared by the UN and World Bank to inform the Madrid meeting underscores the need to move away from Iraq's inequitable hospital-oriented system towards a “decentralised and sustainable model based on primary care, prevention, partnership, and evidence-based policy”. The Madrid conference is predicted to receive a tepid response, owing to the continued political battle over the future governance of Iraq. Donors must recognise, however, that Iraq is a far from homogeneous country and if the current insecurity cleaves the population along tribal, ethnic, and religious lines, the violence will escalate. The time for rebuilding Iraq and the equitable provision of health care is long overdue. The international community must commit itself now to the security and health of all Iraq's people—before it is too late.