Offline: Iraq—the prelude to a global war

Abstract

“US military officials are expecting that Iraq will use chemical and biological weapons against US and allied forces in the event of war”, wrote our American correspondent, Michael McCarthy, on Feb 22, 2003. He reported on preparations by US forces, which seem surreal now, to protect troops in Iraq from nerve agents, anthrax, botulinum toxin, and even smallpox. Just a few weeks earlier, 500 public health scientists from the London School of Hygiene & Tropical Medicine had written an open letter to then Prime Minister Tony Blair on the consequences of a war in Iraq. They drew attention to likely civilian casualties, civil war and a refugee crisis, famine and epidemics, and the effects of conflict on children's health and development. Carolyn Stephens and her co-signatories also pointed (with disturbing prescience) to “the most worrying effect” of a war in Iraq—”its role as an escalator of collective violence”. “Conflict”, they wrote, “escalates after use of collective force, as violence becomes a more common and legitimated form of political or social action.” On March 8, 2003, Elisabeth Benjamin and a team from the New York-based Center for Economic and Social Rights described the preparedness of Iraq's health system to respond to the effects of a war. They reported pervasive weaknesses—in primary care and hospital services, basic equipment, supplies of medicines, and public health. “Our team found that military intervention in Iraq will severely affect an already vulnerable population—a humanitarian disaster is likely to ensue.” On March 20, the bombings on Baghdad began. This week, as violence in Baghdad continued unchecked, the long awaited Chilcot Inquiry published its findings. What was the basis for war? How was the decision to go to war made? How was the war conducted? What lessons can be learned? Answers to these questions have now been offered. But what of medicine and public health? What did the global health community do well? First, awareness of the human crisis in Iraq after 2003 was maintained through a steady stream of reports on the deteriorating health situation, displacement of communities, failing efforts to reconstruct a health system, and lack of international investment into the country. Second, scientists conducted courageous work to estimate civilian mortality. And third, several attempts took place to learn from what went wrong. One small example in our own journal: a decade later in 2013, a theme issue to investigate the effects of war on, among other priorities, maternal and child health, chronic diseases, mental health, service infrastructure, access to essential medicines, environmental health, and brain drain. But we all need to face an uncomfortable truth: failure outweighed success. We did too little to monitor the effects of war on the health of Iraqi citizens. We didn't hold international health organisations accountable for their preparations before the war or for their work in Iraq after the war. We didn't anticipate the severe effects of war on military personnel deployed by politicians into the battlefield. The global health community failed (and continues to fail) to incorporate humanitarian concerns into its thinking and planning. A pervasive institutional risk aversion led us to retreat from applying our knowledge and understanding to complex and fragile settings of conflict. (Those failures and retreats have contributed to ebbing political support for refugees. They have damaged solidarity between nations.) And we failed to consider more deeply the consequences of the Iraq war for the wider Arab World. The 2003 war triggered political destabilisation across the Middle East, fostering conditions for ISIS to flourish—from Mosul in the north of Iraq to Orlando in the USA. The origins of the present refugee crisis in Syria and its catastrophic imprint on the region and across Europe can be traced to the events that began in 2003. The war in Iraq continues to cast a shadow over international politics—and global health. As the historian of Baghdad, Justin Marozzi, has pointed out, the existing sectarian tensions in Iraq are not the exclusive creation of the Americans or British. But the 2003 war did exacerbate polarisation, violence, and ethnic and religious conflict. The future of Iraq's health system will remain bleak for many decades to come. Based on its endowment of natural resources, Iraq should be a prosperous country. The fact that it is not is partly due to the failures of western military intervention—and endemic weaknesses in the international health architecture and its response.