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File: 950901_0404pgf_91.txt
Iraq: Assessment of Current Health Threats and Capabilities
Filename:0404pgf.91
AFMIC Assessment 05-91
15 November 1991
Armed Forces Medical Intelligence Center
Assessment
Iraq: Assessment of Current Health Threats and Capabilities
Key Judgments
Restoration of Iraq's public health services
and shortages of major medical materiel remain dominant
international concerns ([ (b)(2) ] ).
Both issues apparently are being exploited by Saddam Hussein in an
effort to keep public opinion firmly against the U.S. and its
Coalition allies and to direct blame away from the Iraqi
government.
Disease incidence above pre-war levels is more attributable to
the regime's inequitable post-war restoration of public health
services rather than the effects of the war and United Nations
(UN)-imposed sanctions. Although current countrywide infectious
disease incidence in Iraq is higher than it was before the Gulf
War, it is not at the catastrophic levels that some groups
predicted. The Iraqi regime will continue to exploit disease
incidence data for its own political purposes ([ (b)(2) ]
).
Iraq's medical supply shortages are the result of the
central government's stockpiling, selective distribution, and
exploitation of domestic and international relief medical
resources. These same factors will play a role in the ongoing
regional incidence of post-war infectious disease.
Compared with pre-war capabilities, hospital services
have been significantly reduced, with comprehensive medical care
available only to the political elite, the very wealthy, and the
military.
Post-war reporting indicates that Iraq may be storing
nuclear, biological, and chemical (NBC) materials in or around
hospitals in an attempt to conceal them [ (b)(1) sec 1.3(a)(4)
], [ (b)(2) ] . If true, the storage of
these materials is contrary to basic safety tenets and poses a
serious health threat to hospitalized patients and medical staff.
Public Health
[ (b)(1) sec 1.3(a)(4) ]
that restoration of
water, sewerage, and electricity services appears to be limited to
select regions. While the water is dirty in appearance, water
quality reportedly has improved in Baghdad. However, conditions
have not improved correspondingly in Al Basrah or other
Shiite-dominated southern cities and in northern Kurdish regions.
Nationwide restoration of water potability has been slowed by 1)
the destruction of Iraqi's chlorine production capability and 2)
the financial cost of rebuilding damaged petrochemical plants and
the interim requirement of importing chloring products from
aborad. Water purification systems and protable generators
provided through humanitarian assistance have served, at best, as
stop-gap measures. Iraq's Ministry of Health (MOH) continues to
provide public health communiques instructing inhabitants to boil
water, fully cook food, and store food and water in clean
containers.
The MOH appears to be regaining administrative control of the
nation's health care system, but restoration of nationwide public
health programs apparently is not being addressed. Resumption of
public health programs (such as disease surveillance, vector
control, and immunization programs; food and food handler
inspections; bacteriological testing of potable water sources; and
local level primary health services and education) depends
completely on the Iraqi government. Until these programs are fully
reinstated, most Iraqi citizens will remain vulnerable to
otherwise preventable diseases.
Refugee medical care remains a specific concern of
international humanitarian agencies as an estimated 300,000 Iraqi
refugees remain in Iran and another 24,000 are in Turkey. A number
of these refugees are attempting to return to northern Iraq before
cold weather returns to the region. Current reports describe an
influx of 10,000 refugees per week returning from Iran. However,
destruction of villages and current violence in Kurdish areas may
prevent a significant number from reaching their homes, leaving
them without shelter and prone to cold and other exposure-related
injuries and illnesses. Moreover, warehouses containing tents,
clothing, and heating supplies that were provided by the UN and
other international agencies for this contingency are located in
the area of current fighting. Workers at these warehouses
reportedly have fled, leaving those goods unprotected from looters
on both sides of the conflict. Additional humanitarian assistance
for the refugees is not likely to be forthcoming from the Iraqi
Government, although the plight of the refugees continues to be
exploited by Baghdad.
Infectious Disease Incidence
Although current countrywide infectious
disease incidence in Iraq is higher than it was prior to the Gulf
War, it is not at the catastrophic levels that some groups
predicted. Disease incidence above prewar levels is more
attributable to the regime's inequitable post-war restoration of
public health services rather than the effects of the war and
UN-imposed sanctions. Recent intelligence reports from reliable
sources have indicated that life in Baghdad essentially has
returned to normal, with no signs of poverty or food shortages. In
contrast, increased infant and child mortality rates, evidence of
child malnourishment, and poor sanitary conditions continue to
plague vulnerable groups outside of Baghdad, particularly in
southern Iraq.
Because the regime did not report adequate pre-war disease
surveillance data and current disease reporting appears
politically-biased, the current disease situation in Iraq is
difficult to assess. Pre-war disease surveillance data are not
available for comparison; therefore, it is unclear what amount of
current disease incidence reported through the Iraqi Government
reflects normal incidence levels. Recent Iraqi reports linking
increased disease morbidity and mortality (particularly cholera,
typhoid fever, hepatitis A, giardiasis, amebic dysentery,
bruce]losis, and echinococcosis) to vaccine and medicine shortages
created by the international embargo are particularly misleading.
These diseases are fundamentally prevented through basic
sanitation and hygiene, not public vaccinations or curative
medicine. Therefore, much of the current reporting is regarded as
an attempt to gain international sympathy.
In addition, morbidity and mortality forecasts publicly
provided by international and private medical organizations
frequently have been based on incomplete information. Baghdad has
restricted the access of foreign observers, limiting the quantity
and quality of collected data. Many of the early post-war
estimates assumed that health and living conditions would not
improve, which led to significant overestimates of projected
morbidity and mortality rates. Because of the restoration of
essential services and international relief efforts, the United
Nations Children's Fund (UNICEF) recently reduced its estimates of
Iraqi children at-risk from 170,000 children to between 50,000 and
80,000 children.
Infectious disease incidence in areas where services are
restored is likely to stabilize in a range that is somewhat above
pre-war levels, with discriminated groups (particularly Kurds and
Shiites) sustaining substantially higher disease incidence. With
the advent of winter, cases of acute respiratory infections,
preventable childhood diseases (measles, diphtheria, and
pertussis), and meningococcal meningitis are expected to increase
significantly in populations receiving inadequate public health
services. The Iraqi regime will continue to exploit the hardships
of discriminated groups for its own domestic and international
political purposes.
Medical Materiel
Iraq's loudly-proclaimed medical supply shortages are
believed to have been artificially created. Possible evidence of
Iraqi government stockpiling, selective distribution, and
exploitation of domestic and international relief medical
resources has been provided by [ (b)(1) sec 1.3(a)(4) ]
. warehouses at the Samarra
Pharmaceutical Plant (34-12N 043-52E) that were between 50 and 75
percent full (including items looted from Kuwait), despite Baghdad
claims the warehouses were only filled to 10 percent of capacity.
[ (b)(1) sec 1.3(a)(4) ] 400,000 doses of
diphtheriapertussis-tetanus (DPT) vaccine from UNICEF stored at
the Serum and Vaccine Institute in Amiriyia (33-18N 044-17E).
Iraqi leaders are alleged to have sold, for personal profit,
medical materiel and equipment donated by international
humanitarian assistance groups as well as some of the medical
equipment stolen from Kuwait.
The extent of Iraqi medical stores is not known but appears
to be massive. A southern Iraqi medical depot, reportedly
destroyed in the wake of Desert Storm, was reputed to house 10
years of medical materiel. Other large medical supply warehouses
are believed to be distributed around the country. U.S. forces
deployed to Dahuk (36-52N 043-00E) during Operation Provide
Comfort noted that medical personnel at the Dahuk Hospital were
not permitted access to a nearby warehouse filled with medical
supplies. The supplies reportedly had been moved from Baghdad to
protect them from Coalition bombing attacks and were to have
eventually been returned to Baghdad.
[ (b)(1) sec 1.3(a)(4) ]
Health Care Delivery
Health care services for the majority of Iraqis are
basically limited to emergency and acute care services. More
comprehensive health services are believed available at the more
prestigious government medical centers, select private hospitals,
and sob military medical centers (most of which are situated in
remote areas away from public observation). This level of health
care principally is reserved only for those with substantial
financial means or political connections.
The current outbreak of fighting in northern Iraq
reportedly has resulted in large numbers of non-military
casualties. lLocal hospitals, filled to overflowing, are incapable
of handling these casualties and heavily depend on international
medical assistance. The International Red Cross is attempting to
augment local health care services with medical supplies and
personnel. Two, relatively-modern hospitals recently have been
identified [ (b)(1) sec 1.3(a)(4) ] in As Sulaymaniyah, a
focal point in the current fighting. One hospital appears to be a
modification of the 16 identical Japanese constructed hospitals
known to exist in Iraq [ (b)(2) ] . The other
hospital is a modification of four, nearly-similar, new military
hospitals.
Military casualties and medical health care capabilities
have been kept secret from the public. The shroud of secrecy may
be to forestall the negative public outcry that would result if
Iraqis were to observe the inequitable distribution of medical
services and materiel between the civilian and military sectors.
There also is a possibility that a significant number of soldiers
who sustained serious, long-term injuries (such as amputees and
para/quadraplegics) during the Gulf War and subsequent civil war
are being held out of the public eye in clandestine facilities
(remote military hospitals and converted sport stadiums, hotels,
and gymnasiums) around the country. This theory is supported by an
unconfirmed report of an Iraqi order placed in spring 1991 with a
North Korean firm for 17,000 hospital beds and 23,000 wheelchairs.
The order, which is excessive given the relatively minimal
destruction sustained by Iraqi health care facilities, would be
appropriate for large numbers of casualties who are bedridden
and/or possess limited mobility.
Overall, medical materiel shortages and delayed
restoration of public utility services have contributed
significantly to the reduction of Iraqi health care services from
pre-war levels. Surgical and diagnostic capabilities appear to
have suffered the greatest decline as the result of erratic and
insufficient water and electricity services, anesthetic shortages,
equipment failures, and shortages of laboratory reagents and other
diagnostic support material. [ (b)(1) sec 1.3(a)(4) ] have
reported that the Al Khadimiya Hospital in Baghdad (33-22-20N 044-
19-30E), designated by Iraq as the referral facility for [
(b)(1) sec 1.3(a)(4) ] in the event of chemical agent exposure
and believed to be the largest of the Japanese-designed hospitals
constructed throughout Iraq during the mid-1980s, is incapable of
performing electrolyte, arterial blood gas, and serum
cholinesterase evaluations (serum cholinesterase is both a
presurgical screening tool and a method of diagnosing and
assessing nerve agent poisoning). Saddam Hussein Medical City in
Baghdad (33-20-58N 044-22-46E), the government's premier medical
center, is unable to operate its CT scan and other sophisticated
medical equipment because of repair problems, but still is
believed capable of performing routine diagnostic examinations
(xray, ultrasound, and laboratory).
Iraq's medical diagnostic capabilities are further degraded by
lack of qualified medical maintenance technicians. Traditionally,
most medical maintenance in Iraq was performed by Western
contractors. Following the invasion of Kuwait, the majority of
foreign workers departed Iraq and have not returned.
The reduction of diagnostic support specifically impaets the
quality of surgical and other specialty services (such as
orthopedics, gastroenterology, and pulmonary medicine) received by
Iraqis. Although still great, the impact on the quality of
emergency and other primary care services is believed to be less.
Therefore, an appreciable decline in patient care in the primary
care setting is more likely to result among poorly-trained
physicians (believed prevalent throughout Iraq), especially those
confronted with heavy workloads created by the decline in post-war
public health and the civil war. Without diagnostic support, these
physicians are more likely to resort to shotgun therapy, which
commonly relies on multiple-drug regimens. Patient care,
therefore, is further degraded by an increased probability of an
erroneous diagnosis compounded by inappropriate therapy that may
worsen the initial complaint. Additionally, Iraqi health care
providers who practice shotgun medicine waste medical resources
that already are in short supply. Iraqi health care providers
serving in medical facilities that are historically poorly
supported or those having experience with the health care
deprivations associated with the Iran/Iraq War probably are more
capable of providing astute diagnoses without the benefit of
diagnostic tests than most Iraqi health care providers.
Storage of NBC Materials in Hospitals
Post-war reporting alleges that the Iraqi military is
storing nuclear, biological, and chemical (NBC) materials in or
around hospitals in an effort to conceal them from UN special
observer teams. The health threat to patients and medical staff is
borne out by Iraq's historical lack of regard concerning safe
handling and storage of NBC material. Reports of accidental
chemical agent exposure among Iraqi military personnel date back
to the Iran/Iraq War. More recently, [ (b)(1) sec 1.3(a)(4) ]
medical reports found at the Muthanna State Establishment
(MSE; 33-49-56N 043-48-13E, also known as the Samarra Chemical
Warfare Research, Production, and Storage Facility) estimate an
annual chemical exposure accident rate at that facility
approaching 30 percent. [ (b)(1) sec 1.3(a)(4) ] lack of
appropriate detection equipment at Iraqi chemical production
facilities, indicating that Iraq would have a significantly
limited capability to detect a chemical contamination occurring
during the storage of chemical agents on or near hospital grounds.
Moreover, most civilian Iraqi physicians lack the capability to
diagnose signs and symptoms of chemical agent exposure.
Suspect medical facilities believed to be housing NBC
material include the Saddam Hussein Medical City and the Al Rashid
Hospital, both located in Baghdad (33-21N 044-25E), the Saddam
Hussein General Hospital in Kirkuk (35-28N 044-23E), the Mosul
Hospital 0621-28N 043-07-00E), and the Dagalah Hospital (36-09N
044-23E). There also have been unconfirmed reports of chemical
warfare agents stored in the King Hussein Medical Center in Amman,
Jordan (31-57N 035-56E).
Summary
Iraq is exploiting the humanitarian issue to maintain
world sympathy and possibly to extend as long as possible the
influx of free goods. However, Iraq is capable of reversing its
current medical materiel shortages through the equitable
distribution of current stockpiles, the use of proceeds from oil
sales approved by the UN for humanitarian purchases, and the use
of an estimated U.S. $340 million frozen in the Bank for
International Settlements. Iraq has demonstrated its capability to
fund high priority health care sector projects during its costly
war with Iran, as evidenced by the construction of more than 20
major medical treatment facilities and the purchases of Western
medicines and medical technology during that period.
[ (b)(6) ] [ (b)(2) ]
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