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Dr. Richard Garfield talks about the future of health in post-war Iraq.
By Tom Cannell |
We helped the Iraqis fight Iran. Then we fought the Iraqis to liberate Kuwait. Then we blockaded them until we fought them
again. Now we are running their country, at least for a while. None of this has been uncontroversial. Iraq is our Vietnam, not
because we are being beaten, but because we are being divided. As was apparent to me observing a spirited interaction between my
grandfather and a Yale anti-war activist some weeks ago, Americans see Iraq in drastically different ways. What's more, many, if not
most, Americans don't know what to think. They don't trust their news sources or their politicians. They suspect the worst and hope
for the best. With this all in mind I decided to take the readers of this magazine to speak with Richard Garfield.
Garfield is a professor of international nursing at Columbia University. Given his interest in health under the conditions of war
and economic sanction he has often focused on (you guessed it) Iraq. Working with UNICEF and the Iraqi Ministry of Health he worked
on monitoring the progress of the Oil For Food program, which allow some cessation of the US-led embargo in 1996. Since the most
recent invasion he authored a lengthy background report on health and nutrition in Iraq for UNICEF and the WHO (see "additional
reading" below), and is currently at work on a similar report for US agencies. Most importantly he has traveled throughout Iraq many
times. During Saddam's reign he was a rarity; a public health worker who had some access to the country. He speaks on the subject with
a fluency and unusual candor.
I visited Dr.Garfield on a Sunday morning just before Thanksgiving. He lives,with his family,in a tucked away apartment
in the Marble Hill neighborhood of the Bronx. He is bearded and cheerful. While he did dishes I asked him every question after
question. I was distracted by the large carp he keeps in an aquarium under his kitchen counter.
Garfield was in Iraq throughout the summer, working with a Los Angeles-based NGO called the International Medical Core. It
is a delicate time for NGOs in Iraq. The recent anti-US bombings have driven some away. An attack on the Baghdad office of the
International Committee of the Red Cross was especially menacing. There are now only about six NGOs operating in Iraq, trying to do
their jobs while keeping their profile as low as possible. "When the occupation began," said Garfield, "a map was made showing the locations of different international organizations in Baghdad and
those groups that were left off it felt slighted. Now many of those groups would do anything to get off the list."
Despite this danger, the present is full of potential for those who work supporting Iraqi health. The UN sanctions, which were
complicit in the high mortality rates of the 90s in Iraq, are over. The sanctions shut all air and sea routes into Iraq, so that even supplies
such as medicines and surgical equipment, which weren't officially barred, could very rarely find their way in. After the inception of the
Oil-for Food program in 1995, health improved, but only slightly. Garfield compares the program, which allowed almost five billion
dollars of medicine and health supplies to enter the country, to the Marshall Plan in terms of funding per-capita. Its limited success
he blames on mismanagement by the Iraqi government. The upshot was a decade of decay of almost every major health-related system
(sewage, electricity, etc.). Now the infrastructure has to recover, not only from this neglect, but also from the damage inflicted during
the US bombings during the most recent invasion and from the subsequent looting. "It was really the looting that caused the most
damage," says Garfield, "water systems were down in lots of areas. I raise my eyebrows, a little confused. Garfield chuckles, "Yeah, I
can see how sitting at home in America reading The New York Times it might be difficult to imagine how looting could damage sanitation
systems, but you have to understand that people will break in and steal the pumps to sell on the black market." With damaged pumps,
people will be drinking unclean water, which has laid the foundation for high child mortality rates in Iraq for the past ten years. One of the
two the most common causes of death for under-five-year olds in Iraq is diarrhoeal disease (the other is respiratory illness).
The under-five mortality rate in Iraq before our most recent invasion stood at slightly less than 120 per 1,000 live births. This
rate is comparable to famine-stricken Chad (118 per 1,000) and Malawi (117), where the AIDS epidemic rages. You would have to
go to war-torn Sierra Leone (180) or Angola (172) to find rates much higher. The challenge to public health officials, explains Garfield,
is not only that infant mortality is so high, but that, based on the health resources and educations levels of the country, even during
the sanctions, there has been little reason for infant mortality to be so high. The Iraqi medical system, developed by Saddam Hussein
during the 1970s was western in bent and featured well-funded hospitals capable of performing sophisticated procedures. Free
health care was provided to all Iraqis, thanks to oil wealth. Saddam's desire to boost Iraqi population led him to launch an aggressive
child survival campaign and under-five mortality in 1990 stood at 56 per 1,000 and falling, well below the average for Middle Eastern
countries. That, of course, was right before the invasion. It was all down hill from there. The combination of bombing by US and its
allies during the 1991 war and the suffocating effect of five years of hard sanctions led to a deterioration of the infrastructure crucial to
providing and facilitating health in Iraq. Paradoxically the material for making war is often also crucial for health care. Chlorine can
be a weapon, but it is also used to treat water. The same fuel that powers tanks and rockets runs ambulances. Water systems failed,
electricity grids blinked on and off, and a generation of Iraqis was raised in a time of infection and malnutrition causing sickness and
death, particularly among the very young. Iraqi infant mortality rate doubled. In a world where infant mortality rates have declined
dramatically, such a doubling has occurred only twice before.
The plight of the Iraqi children became widely publicized,
inspiring a broad range of people and institutions, including the UN Sub-Commission on Human Rights, to call for an end to the
sanction. It was these humanitarian concerns, at least in part,that forced the passage of the Oil-For-Food program, which is credited with improving conditions in Iraq at least marginally and saving
lives.
How many dead were there? The number was a rallying cry in the movement to lift the sanctions. "Millions of Iraqi babies" became
an often-cited figure. Dr. Garfield puts the actual number at around 500,000 excess deaths, drawing on data from a 1999 UNICEF
study in cooperation with the government of Iraq. At the same time Garfield allows, "the numbers of dead from the embargo will
never be fully known." The death toll, although a health statistic, became political and detached from the actual practice of public
health through propagandizing and misuse of numbers by all parties involved. The numbers Garfield cites came from a UN survey in
1999, but, he bemoans, "even the UN often didn't go with its own data." Concerning guilt, Garfield can only point the finger in all
directions. Sanctions cut the Iraqi GNP by 85%, which could not fail to have sad consequences for the health of the nation. And now that
we know the sanctions would not avoid violence, they seem particularly regretful. On the other hand, Saddam, enjoying the international
sympathy he received during the sanctions, seemed to "go out of his way to keep things bad," even during the Oil-For-Food program.
A particularly unfortunate misstep, which Garfield cited several times during our discussion, was the Iraqi inclusion of infant formula
in the rations made available during the sanctions. Just at a time when infection and malnutrition threatened the very young, Saddam encouraged Iraqi mothers to deprive their
children of the immune benefits of breast-milk. WHO studies suggest that in a child in a resource poor country is six times more likely to
survive when feed from the breast than from the bottle. The formula rations are one way in which the sick and dying children of Iraq were
at least partly a reflection of the policies of their government that was idiotic, indifferent or malevolent.
Now, of course, the specific debate over the sanctions against Saddam is academic. There remains the same political tension that touches everything involved with Iraq, a fear of imperialism versus
fears for national security. The huge apparatus that the United States and its allies have constructed in Iraq under the authority of the
Coalition Provisional Authority is under powerful political scrutiny from every direction. In fact the criticism that Garfield makes of the
current CPA efforts in terms of health is they may be distracted from concrete humanitarian goals by the demands of political ideology.
The recent dismissal of all Iraqi officials involved with Saddam's Baathist party is an example. Many Baathists, teachers and
engineers, can no longer offer their services to a country that badly needs them. Garfield is concerned that rather than building on and
working with existing Iraqi strengths, the CPA is "looking to invent an American Iraq." One of the first drives that the CPA embarked
on was an anti-corruption campaign. Corruption, Garfield points out, "is sort of an American idea." Much of the payoffs
and nepotism that CPA officials abhor, "aren't really seen by Iraqis as corruption but rather a fact of the way that business
is transacted." At a time when the establishment of health services is vital for the stability of the country and credibility of the US
effort, it seems that an anti-corruption drive should be a secondary concern.
Up until know the CPA hasn't seemed to grasp the
lessons of public health. Of the $87 billion Congress recently appropriated for our expedition into Iraq, $16 billion is
going towards humanitarian efforts (the rest is for the military). Of that figure, $800 million is for health projects. Unfortunately, the
CPA has committed most of this money towards building hospitals, which look good, but "are entirely the wrong thing for child survival."
Broader,community-based primary care has not become a priority. The haphazard progress made in addressing the damage done to
the infrastructure has come at the hands of the State Department's Agency for International Development (USAID).
At the same time, Garfield praises the CPA officials as "hard- working and dedicating," and is generally optimistic about the possibility about significantly improving health in Iraq. The high
literacy, high rates of urbanization, mass media capacity and the skeleton of a top-notch health system are all definite positives.
Less effort will be required to shore up health than would the case in most third-world African countries where lack of education and
total lack of infrastructure are basic enduring problems. In contrast, the problem in Iraq, thinks Garfield, will not be establishing health
services, but allowing people to have access to them, given security concerns. The major impression I draw from Garfield's work is the
sobering fact that the vast majority of war's victims are not killed with guns, but suffer slowly throughout the years from the confusion
and destruction is essential to war and is certain to follow in its aftermath. In recent months, the quality of health has suffered,
not so much because the hospitals have been destroyed by looting (many have not) but because "people have simply been afraid to
leave their houses." In the presence of guerrilla attacks throughout the country communication and transportation will be a problem
and an enormous expense for both NGOs and the CPA in trying to provide care and for Iraqis trying to benefit from it. "We are very
close right now," says Garfield, "to the point where health efforts by international personnel just aren't operable. It's very difficult
to move around and very expensive to do so." At the same time, Garfield hopes for the best, "There aren't that many Iraqis that want
to fight compared with how many want to work. I'm worried about the point of no-progress, but I don't think we'll reach that point."
NOTES/ADDITIONAL READING
Packer, George. "War After the War." The New Yorker. November 24,2003.
Casa, Kathryn. "Iraq embargo Toll Now Surpasses War's Horrors."
Washington Report on Middle East Affairs. July/August 1995.
Garfield, Richard and Juan Diaz. Iraq: Social Sector Watching Briefs: Health and Nutrition. UNICEF/WHO. July 2003.
Garfield, Richard. "Potential Humanitarian Impact of War With Iraq." Global Policy Forum - UN Security Council. February 22, 2003.
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