Democrats & Liberals: Archives

The big worry now is the Sunnis, for whom turnout was low - whether because of fear, objection to their impending minority status, or some combination. It remains to be seen if they can be brought into the government, or not.

Bert,
You just can not admit that you and your party are wrong. You really are a shameful human being. Your hatred for Bush and this country goes so deep that you can not even contimplate a great thing if it hit you upside the head. Open your eyes man. The reason you people keep losing, is becuase main-stream America is so far from where you and your party are. You all need to wake up and realize that you will continue to lose your voice because of your far left views. I’m really trying to help you. But if you want to keep digging a hole for your party to fall into, go ahead. You are only making my side more appealing to Americans, and your side less. Good-bye for now. Keep it up, PLEASE.

Greg,

When someone comes to a WB comment thread of one of my entry posts, and directly unloads on me - while choosing to completely ignore or respectfully address any points in my commentary - do you realize how much that validates my argument?

Someone once said, being a U.S. taxpayer means never having to prove you love this country. And, until ‘you and you’re side’ earn the right to shut me down, I’ll be here helping your recruitment efforts. But, I have just one favor to ask of you.

You’d be perfect for making our side more appealing. You available?

Look, we won once before, only to snatch defeat from the jaws of victory. This is not about devaluing the elections, but making sure they constitute the beginning of our redemption of this war, rather than the beginning of a second decline.

We must see our own efforts in a skeptical, analytical eye. If we leave too much to chance, we end one day pushing our luck too far.

Unfortunately, Bush and his people are too interested in just railroading on. Well, if you don’t take care of the rails, sooner or latter things jump the tracks.

I’m confused - how exactly does a successful election make the blue side wrong, about anything?

There were still no WMDs
The insurgency is still strong
We still have no way out.

Just because the “leaders” of Iraq are now democratically elected does not mean anything significant has changed. The US military and insurgent leaders are still the two dominant factions in Iraq, and that will be seen the minute the new Iraqi “government” makes a decision that goes against US interests.

First of all, no one doubted that a vote of some kind was going to take place. The question was always, will it solve any of the problems in Iraq? Will it create a democracy?

I just read an interesting Fareed Zakaria article. Before the invasion, he wrote a book on how to build a Middle Eastern democracy, so it’s kind of an “I told you so” article,

Unless there is a major change in course, Iraq is on track to become another corrupt, oil-rich quasi-democracy, like Russia and Nigeria… Russia and Nigeria aren’t terrible regimes. But it was not what many of us had hoped for.

And to back up Bert, in my local paper, Janadas Devan (the best editorialist on US politics you’ve never heard of) writes,

The jihadists lost on polling day, not solely because ordinary Iraqis were brave enough to defy their threats in going to the polls, but because Washington finally did what it had failed to do for close to two years - provide sufficient force to secure the peace. It is order that makes possible democracy, not the other way round, and it remains to be seen how long the US can sustain its pre-election show of force.

On a historical note, the emphasized truism is also the strategy the British used to successfully defeat the Communist insurgency in Malaya in the 50’s and 60s: “You can’t expect any support from people you can’t protect.”

The election turnout was better than expected because, in the weeks before the election, Bush increased the number of troops in Iraq, stepped up raids and arrests, and locked the country down on election day. It remains to be seen whether that effort - which should have begun two years ago - will be expanded and sustained, and it’s still an open question what kind of democracy this election will produce.

Bert, good article.

I agree with this 100%:
“For nearly two years, Iraqis have been frustrated and patient, as well as, lied to and ignored. Their understanding of Democracy to this point, should be the promised restoration of basic services, an expanding economic model that continues to generate jobs of decent wages, which would then decrease the number of those tempted to join an Insurgency out of anger, fueled by powerful rhetoric and dangerous idleness.”

Again and again it goes back to the fact that the administration tried to wage war on the cheap. By not going in with enough troops the entire infrastructure of the country fell apart, and by not rebuilding it during the past two years they have done nothing but grow the insurgency, as well as an increasing desire among the average Iraqi citizen to see the backs of our troops. When you think about it, they were really incredibly patient - because those citizens waited a full year without basic services before beginning to mount real vocal opposition to our presence there.

“Yet I counter argue, that their stronger impetus was to secure the one promise they could be assured their occupiers could not renege on - the power to send them packing.”

I think you are absolutely right. But since we seem to be building permanent bases in Iraq, I don’t think the administration is going to go along with their wishes.

There are also some reports coming in that the Iraqi’s voted in such large numbers because they were afraid that if they didn’t they’d starve.

By not going in with enough troops the entire infrastructure of the country fell apart, and by not rebuilding it during the past two years they have done nothing but grow the insurgency, as well as an increasing desire among the average Iraqi citizen to see the backs of our troops.

Adrienne,

You must enjoy preaching to the choir, because those of us who take the time to do a little research know that statements like those above are simply not true. So, either you are trying to commiserate with the other the other blue county folks or you are trying to deceive anyone who takes the time to read your posts.

You see, the infrastructure in Iraq did not fall apart because of troop strength or anything else that happened following the start of Operation Iraqi Freedom.

Mr. Jim Guy of USAID / Bechtel made the following statements concerning Iraq’s electrical power grid on November 18, 2004.

And the biggest problem has been well enunciated all throughout the last 18 months. The infrastructure suffered from tremendous lack of repair and maintenance over the 25 years of Saddam’s reign. The shortage of spare parts has been well known.

Mr. Fred Guymont also of USAID / Bechtel made the following statements concerning Iraq’s Water and Waste-Water network during the same November 18 briefing.

As Jim mentioned, there was very little investment, either in capital, infrastructure or in O&M during the last 20, 25 years. As a result of that, Iraq could not supply potable water to its growing population, and waste water treatment plants fell into total disrepair.

And I mentioned, no waste water treatment plant in Iraq was operable when we arrived. We are rehabilitating the three waste water plants in Baghdad. We’re doing that—some of that work in association with the CPA contracts that were let months ago and overseeing the installation of CPA and Iraqi funded equipment.

A portion of one of those plants is completed and in June of this year, Iraq began treating waste water for the first time in over 20 years. Now, those three treatment plants should be completed, fully completed, by early 2005.

I think that you need to look at the surveys of the Iraqi people along with empirical data to get a true picture to the question of are their lives are better today than they were Pre-war.

I will not list all the areas that help to disprove your statement above, but if you are truly interested in seeing them they are posted in my post under.

SERVING THE KOOL-AID

5)Irrigation canals in need of cleaning in km: May 2004 level 20,000 km vs. October 2004 level 3,500 km

7)Do you think Iraq today is generally heading in the right direction or wrong direction? (12-26 to 1-7-2005): Right Direction 48.6%, Wrong Direction 39.2%

8)Thinking about the future, do you feel that things will be better, the same or worse in (12-26 to 1-7-2005): 6 months Better 52.3%, Same 23.8%, Worse 14.1%

9)On Iraqi Standard of Living, Since the invasion, which or the following happened to you personally or to members of your household?

a.Gone without Electricity for long periods of time: Within past 4 wks 3%, Since the Invasion 44%, In the Year Before the Invasion 68%

b.Without Clean Drinking Water for long periods of time: Within past 4 wks 4%, Since the Invasion 28%, In the Year Before the Invasion 36%

e.Gone without Public Sewage System: Within past 4 wks 1%, Since the Invasion 31%, In the Year Before the Invasion 37%

11)If Coalition Forces left immediately, would you feel more safe, less safe or no difference? Nationwide: Less Safe 71%, Baghdad: Less Safe 75%

12)Baghdad Public Opinion Poll (Aug-Sep 2004) Was ousting Saddam worth the hardships endured since the Invasion? Yes 62%

13)Baghdad Public Opinion Poll (Aug-Sep 2004) Would you like to see U.S. troops stay longer than a few more months? Stay Longer 71%

It does not take much to find evidence to show that great strides are being made in rebuilding the infrastructure and that the people of Iraq are better off now than pre-war. Unfortunately, the media is not going to provide this information for you, you have to be willing to expend a little effort.

Kirk

Do you have a citation for those figures?

Kirk,
“either you are trying to commiserate with the other the other blue county folks or you are trying to deceive anyone who takes the time to read your posts.”

Is this an unacceptable source of information? Or are you just accusing me of being a liar because I’m a leftie?

Children Pay Cost of Iraq’s Chaos Malnutrition Nearly Double What It Was Before Invasion

By Karl Vick
November 21, 2004

“BAGHDAD — Acute malnutrition among young children in Iraq has nearly doubled since the United States led an invasion of the country 20 months ago, according to surveys by the United Nations, aid agencies and the interim Iraqi government.
After the rate of acute malnutrition among children younger than 5 steadily declined to 4 percent two years ago, it shot up to 7.7 percent this year, according to a study conducted by Iraq’s Health Ministry in cooperation with Norway’s Institute for Applied International Studies and the U.N. Development Program. The new figure translates to roughly 400,000 Iraqi children suffering from “wasting,” a condition characterized by chronic diarrhea and dangerous deficiencies of protein.
“These figures clearly indicate the downward trend,” said Alexander Malyavin, a child health specialist with the UNICEF mission to Iraq.
The surveys suggest the silent human cost being paid across a country convulsed by instability and mismanagement. While attacks by insurgents have grown more violent and more frequent, deteriorating basic services take lives that many Iraqis said they had expected to improve under American stewardship.
Iraq’s child malnutrition rate now roughly equals that of Burundi, a central African nation torn by more than a decade of war. It is far higher than rates in Uganda and Haiti.
“The people are astonished,” said Khalil M. Mehdi, who directs the Nutrition Research Institute at the Health Ministry. The institute has been involved with nutrition surveys for more than a decade; the latest one was conducted in April and May but has not been publicly released.
Mehdi and other analysts attributed the increase in malnutrition to dirty water and to unreliable supplies of the electricity needed to make it safe by boiling. In poorer areas, where people rely on kerosene to fuel their stoves, high prices and an economy crippled by unemployment aggravate poor health.
(snip)
Iraqi health officials like to surprise visitors by pointing out that the nutrition issue facing young Iraqis a generation ago was obesity. Malnutrition, they say, appeared in the early 1990s with U.N. trade sanctions championed by Washington to punish the government led by President Saddam Hussein for invading Kuwait in 1990.
International aid efforts and the U.N. oil-for-food program helped reduce the ruinous impact of sanctions, and the rate of acute malnutrition among the youngest Iraqis gradually dropped from a peak of 11 percent in 1996 to 4 percent in 2002. But the invasion in March 2003 and the widespread looting in its aftermath severely damaged the basic structures of governance in Iraq, and persistent violence across the country slowed the pace of reconstruction almost to a halt.
In its most recent assessment of five sectors of Iraq’s reconstruction, the Center for Strategic and International Studies, a Washington research group, said health care was worsening at the quickest pace.
“Believe me, we thought a magic thing would happen” with the fall of Hussein and the start of the U.S.-led occupation, said an administrator at Baghdad’s Central Teaching Hospital for Pediatrics. “So we’re surprised that nothing has been done. And people talk now about how the days of Saddam were very nice,” the official said.
The administrator, who would not give his full name for publication, cited security concerns faced by Iraqi doctors, who are widely perceived as rich and well-connected and thus easy targets for thieves, extortionists and the merely envious or vengeful. So many have been assassinated, he said, that the Health Ministry recently mailed out offers to expedite weapon permits for doctors.
Violence has also driven away international aid agencies that brought expertise to Iraq following the U.S. invasion.
Since a truck bombing at the U.N. headquarters in Baghdad killed more than 20 people last year, U.N. programs for Iraq have operated from neighboring Jordan. Doctors Without Borders, a group known for its high tolerance for risk and one of several that helped revive Iraq’s Health Ministry in the weeks after the invasion, evacuated this fall.
CARE International closed down in October after the director of its large Iraq operation, Margaret Hassan, was kidnapped. She is now presumed to be dead. The huge Atlanta-based charity had remained active in Iraq through three wars, providing hospitals with supplies and sponsoring scores of projects to offer Iraqis clean drinking water.
By one count, 60 percent of rural residents and 20 percent of urban dwellers have access only to contaminated water. The country’s sewer systems are in disarray.
(snip)
The nutrition surveys indicated that conditions are worst in Iraq’s largely poor, overwhelmingly Shiite Muslim south, an area alternately subject to neglect and persecution during Hussein’s rule. But doctors say malnutrition occurs wherever water is dirty, parents are poor and mothers have not been taught how to avoid disease.
(snip)
Iraqis say such conditions carry political implications. Baghdad residents often point out to reporters that after the 1991 Persian Gulf War left much of the capital a shambles, Hussein’s government restored electricity and kerosene supplies in two months.”

If you want the many personal stories related by Iraqi’s in the article, click on the link.

Mental Wimp,

Do you have a citation for those figures?

http://www.brookings.edu/fp/saban/iraq/index.pdf#search=’iraqi%20opinion%20polls’

You will find that this is a very comprehensive report in the areas covered. You will also find that there is data that will support the arguments on both sides of the debate.

Adrienne,

Is this an unacceptable source of information?

This is a newspaper article from the Washington Post. There are no footnotes or references just the authors statements of what was in the studies. I myself have not been able to find the actual studies to review.

Or are you just accusing me of being a liar because I’m a leftie?

No, I do not think all lefties are liars just wrong on most issues.

Your statement is in direct conflict with the facts included in the Brookings Institute report that I cite. Here there are facts, figures, footnotes and references to support the data and opinion polls.

In fact the Brookings Institute report cites the very same article you post above and includes a small table showing the malnutrition numbers listed in the article. Brookings then follows the table with the following footnote.

We find it dubious that a country with the per capita income of Iraq could have child mortality figures as high as this.

The Center for Strategic Studies states

Extensive damage and disrepair of the Iraqi Health Care System is largely the result of over two decades of neglect

Just one more statement that clearly shows the condition of the Iraqi infrastructure is largely a direct result of Sadam and his regime not By not going in with enough troops the entire infrastructure of the country fell apart.

The infrastructure had already fallen apart Operation Iraqi Freedom did not cause it. Sadam stole millions of dollars from the Oil For Food program and continued to build new palaces while his people suffered and their country fell down around their ears.

Don’t blame that on the coalition or the president.

Kirk:
“This is a newspaper article from the Washington Post. There are no footnotes or references just the authors statements of what was in the studies. I myself have not been able to find the actual studies to review.”

Neither can I, though that may be because the stats were compiled by the Iraqi Health Ministry and Norwegian IAIS, and I can’t read either of those languages. But this may offer better proof because the UN was also involved with the study, and this is an official UNAMI webpage (that stands for UN Assistance Mission in Iraq).

“Your statement is in direct conflict with the facts included in the Brookings Institute report that I cite.”

I am utterly gobsmacked.
Brookings! I guess next you’ll be quoting from the Heritage
Foundation? LOL!

“The infrastructure had already fallen apart”

It was in poor shape before, now its been completely demolished. And anything that wasn’t nailed down has long ago been carried off by looters.

“Operation Iraqi Freedom did not cause it.”

Yes, it did.
We needed more troops to immediately establish order, but Dubya and Co. wouldn’t hear of it, even though they were repeatedly warned by their own generals that chaos would be the result of having too few.

“Don’t blame that on the coalition or the president.”

Oh, but I do. There is no one else to blame for the horrific events which unfolded in Iraq but this president and his administration.

Adrienne,

Your UN link is nothing but a copy of the Washington Post article. Relying on the UN as your authoritative source of information does not say much for your argument. Their credibility on Iraq is worthless considering the OFF scandal and Kofi’s own son proffiting from the mess.

And yes the infrastructure had already fallen apart. I challenge you to find a single credible account of the water, waste-water or electrical infrastructure that states these systems were in even decent working order prior to OIF. Again OIF did not cause the problems with the infrastructure. Sadam’s greed and the fraud he perpetrated with the French, UN and Russians is what caused it.

I realize you blame everything on the president. You have no choice. To do otherwise would force you to take a deep look into the mirror and admit you were wrong.

Haha! Are you saying that the shock and awe bombardment of Baghdad missed every single piece of infrastructure? If everything was broke before OIF, how come they’re complaining that the infrastructure was better under Saddam? Adrienne’s got you on this one, Kirk.

Kirk:
“Your UN link is nothing but a copy of the Washington Post article. Relying on the UN as your authoritative source of information does not say much for your argument.”

Okay, fine. Then how about some descriptions that would back up the IAIS study and the Post article concerning Iraq’s health situation after our invasion and occupation, and what occured as a result of the administrations many failures, from the British medical journal ‘The Lancet’? Would that also be unacceptable?

I’ll paste it here, rather than giving a link because everyone must register in order to view their articles.

World Report
An opportunity lost

“Iraq is on the road to political stability, but its public health crisis is far from over. Looting and lawlessness have decimated health services, and worsening security prevents access to those still functioning. Could Iraq’s health have been better handled? Hannah Brown investigates.

The stench of raw sewage rising from Basra’s streets haunts Simon Fradd, a British physician who spent 3 months as a health adviser in Iraq. A half-finished sewage treatment plant sits at the edge of the city, but construction stopped 7 years ago. The drains that are supposed to carry human waste into the Shat Al-Arab river are blocked. And although plans to rebuild health facilities are getting underway, “nobody had actually thought about getting this sewage off the streets”, says Fradd. It is clear that Iraq is still in the throes of a public health crisis.

On June 28, 2 days ahead of schedule, the US-led Coalition Provisional Authority (CPA) finally relinquished command, transferring power to the Iraqi ministers-in-waiting, who were picked for their positions by the new governing council. This step is undoubtedly a momentous one for Iraq. But the coalition reign has left much of the country little better off—if at all—than when the war ended a year ago. Security is still poor and working conditions for advisory teams and relief workers are all but impossible.

Some progress has been made towards rebuilding hospitals and securing medical supplies, but basic needs remain unmet. Untreated sewage still runs down the streets, running water is undrinkable, and the sky-high unemployment rates mean few can afford to feed and water themselves. More disquieting is the fact that diseases are starting to take hold just as collapsing communications systems have forced many health workers to concede defeat and return home. The newly independent Iraqi health ministry has quite a job on its hands.
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Crumbling clinics

Fradd was part of a nine-person CPA team; only two of his colleagues now remain in Basra. He returned to Britain after worsening security meant he could no longer travel to clinics in other parts of the region, so was unable to do his job. “The conditions are frankly third world”, he says. The buildings themselves—many almost 100 years old—are crumbling. And even where units have been refurbished since the war, poor cleanliness and hygiene are a major problem. “You would weep if you saw the health centres”, he adds.

Clinics are running on skeleton staff and there is a severe shortage of people who have appropriate training. “They talk about having a lot of nurses, [but] there are only about 300 qualified nurses in the whole of Iraq”, Fradd explains. “That’s for a population of 20 million people.”

Medical equipment and drugs are in very short supply. Typically, one tiny shelf of drugs is all that is available for a clinic that serves 60 000 people. Such conditions inevitably promote disease. Official figures record around a thousand cases of watery diarrhoea a week in Basra, but Fradd believes “there are probably 10 or even 100 times as many cases that go unreported”. Measles is also a big problem—despite successful immunisation programmes it is still the number one killer for children. And the situation is set to get much worse as temperatures soar to 50ºC in the scorching Iraqi summer. “I think there’s a real danger of typhoid and cholera really coming out in a big way”, Fradd warns.

Reports from health workers such as Fradd, who have alerted the central authorities to increasing rates of disease, constitute much of information available about the health situation. WHO and other non-governmental organisations (NGOs) took charge of restoring health services and collected local data on communicable disease. But since the war started, there has been no population-based surveillance system in place to monitor outbreaks or to measure the effectiveness of any interventions. “Neither the CPA people, nor the leaders of the ministry of health saw any priority in doing population-based assessments”, says Richard Garfield, a consultant for various agencies including WHO and UNICEF. He believes the lack of a public health focus among the coalition’s leaders has delayed Iraq’s recovery and may have cost lives.
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Conflicting priorities

In charge of the health team in Baghdad was a loyal republican called James Haveman, who was appointed by the Bush administration and brought in just one month after the end of the war. Haveman replaced Frederick Burkle, a professor of public health and an experienced planner of complex emergencies, as senior adviser to the health ministry and de facto ministry chief. He had no experience of public health and no experience of working in developing countries. But, reveals Garfield, he was not alone. “In the entire [health] team there was only one person with any training in public health”, he says.

Haveman started his term in Iraq by pledging US$2 million for a renovation project on the ministry of health building—a move that infuriated relief workers. “I was thinking about health messages on TV warning parents to boil water before feeding it to kids, measles immunisation programmes, and re-establishing reference laboratories … These are what public health people think of as top priorities”, exclaims Garfield. But he concedes that Haveman’s dedication to securing a good working environment did enable health workers to actually get things done—something that was rarely possible when the building was a target for looters.

The other main priority Haveman identified was abolishing corruption in the provision of medicines. Again, says Garfield, the sentiment was commendable, but the way Haveman’s team went about implementing this plan showed little understanding of Iraq’s culture and society. The CPA focused on eliminating the state-run medicine and supply company, Kimadia, which was viewed as corrupt and inefficient. A private system was to be put in place to introduce competition, but instead the process ground to a halt.

Garfield believes that labelling Kimadia’s inefficiency as corruption was wrong. “In developing countries, people involved in the system don’t necessarily see corruption in the same way we do”, he explains. “They see it as one hand washing the other, or necessary payments to make things work.”

The CPA was forced to backtrack quickly when it became clear that its reforms were not going well. Kimadia is now limping along, as before, riddled with inefficiencies. One piece of progress has been made, however. “The 10% kickback to the Baath party has gone”, says Garfield. “So we got 10% more medicines out of the system by having a war.”

Despite not being a top priority for the CPA administration, many hospitals managed to function near normally after the war. And concerns about staff refusing to work under an occupation turned out to be unfounded. The main reason why these institutions were able to continue is that they were used to operating with little support. “The truth is, the central government had supplied them with very little for 3 years before the war”, explains Garfield.

To make enough money for full salaries, cleaning supplies, and other essential goods, the hospitals financed themselves with a “user fees” scheme. After the war, and without understanding the necessity of this programme, the CPA proclaimed that user fees should be abolished “to help restabilise society and give a benefit to people”. In actual fact, it had the opposite effect. “There were no cleaning supplies”, says Garfield. And soon there was a crisis in the supply of oxygen.

The management of this crisis confirmed critics’ claims that the coalition did not understand the problems it faced. Hospital administrators told the CPA that they had no oxygen; the CPA officials immediately assumed that the factories had stopped producing.

“But that wasn’t the case”, says Garfield. The real problem was that hospitals couldn’t afford the price of $9 a canister and were instead offering $4. The manufacturers wouldn’t produce the gas for that amount, so that system fell apart. “The Americans were busy trying to import oxygen-separating plants when all they needed was a bit of petty cash”, says Garfield. The user-fee ban was quietly withdrawn around a month later.

Iraq, one year on

In a tuberculosis clinic in Basra, physicians are struggling with outdated equipment, ineffective drugs, and increasing incidence of drug-resistant disease. Health adviser Simon Fradd says staff are subjecting themselves to risks of infection on a daily basis, simply because they have no way to protect themselves.

“The clinic has two x-ray machines, both built in the 70s”, recalls Fradd. “But only one works.” There is no lead shielding for people operating the machine, so they are taking their chances with the radiation.

The plating machine—a unit to help put sputum samples onto microscope plates—is also dysfunctional. “It is meant to have an extractor fan to make sure that the bugs travel away from whoever is plating it up”, explains Fradd. But the fan isn’t working. As a result, every time someone uses the machine they are running the risk of getting infected themselves.

Drugs are in short supply, but the clinic does have some stocks of first-line drugs for tuberculosis. If these do not work however, there are no second-line options. If someone does not respond to the first course of drugs, explains Fradd, the clinic doctors simply give them a second course. “If people do not respond, they just get sent them home”.

Overusing drugs in this way promotes drug resistance. Fradd says the incidence of drug-resistant tuberculosis in Basra has more than quadrupled in the past year. Sensitivity kits are not available to tell whether the disease is truly resistant or not, so patients’ responses to drugs are the only indicator. But because there are no isolation units, non-responders are just sent back into the community, where they are free to pass their resistant disease onto others. “You can’t do anything else”, says Fradd. “You can’t just isolate somebody until they die.”

One of the reasons why so many simple mistakes were made was that the CPA was reluctant to take advice from people with experience of Iraq—namely UN agencies and humanitarian relief organisations. Such groups had been working in Iraq throughout the 1990s when sanctions were in place, and were familiar with the needs of the population and the health infrastructure. But Burkle claims the CPA viewed these groups as “ineffective, inefficient, and no use at all”. He recalls: “There was total disregard of the UN, UN agencies, and the NGOs that were serving the UN.” And by failing to establish good relationships with humanitarian organisations, the “coalition military forces denied themselves valuable expertise”, adds Burkle.

Leadership in the CPA was strictly top-down, which meant that all activities had to be approved through the central office in Baghdad. Aiming to keep a consistent set of priorities throughout the country, this policy also required UN agencies and NGOs to conform to the CPA’s wishes. But Garfield says this management style focused “more on controlling the health system than leading it”. Haveman demanded that all projects had to be approved by his office in Baghdad, but by doing so, he introduced delays into the relief effort. “We were told not to do anything unless it was approved”, explains Garfield, “but they didn’t get around to the processing.”

Burkle argues that the centralised system of government also contradicts public health principles. Communications between cities in Iraq were poor, so isolated CPA representatives in southern cities were frequently forced to fend for themselves.

But it was the lack of importance placed on a decent surveillance system that most angered public health workers in Iraq. Because no data were collected until months after the war ended, there is now no way to assess whether health has improved.

No one from the CPA was available to answer The Lancet’s questions.
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An opportunity lost

So why were fundamental principles of public health swept aside? According to Burkle, the answer to this question can be traced back to the US decision to put the Department of Defense in charge of post-war humanitarian efforts, rather than choosing the civilian State Department team, which had extensive experience dealing with complex emergencies.

The Department of Defense planners assumed the war would be short and that there would be no humanitarian crisis, explains Burkle. They decided there would be little or no population displacement and no infrastructure loss. Defence chiefs also assumed that the private sector could handle reconstruction “funded by oil revenues and supported by a cooperative Iraqi population”.

In line with this policy, the Pentagon appointed leaders like Haveman, who, according to former Iraqi adviser Tim Carney, “shared their belief that a capitalist democracy could be quickly installed in the country”. Cooperation with UN agencies and relief organisations was deemed unnecessary, because it was thought there would be no humanitarian crisis to handle.

In one respect they were right. The war itself caused little damage to Iraq’s health infrastructure because troops were careful to spare essential buildings. But looting and lawlessness in the conflict’s wake were devastating. Hospital, clinics, pharmacies, laboratories, and offices were all ransacked. And for a long time after the war officially ended, security risks prevented humanitarian workers from assessing how bad the situation was. Disease reporting and outbreak investigation were severely hampered because collection of data was difficult or impossible. “It was a tragic situation”, says Garfield.

In the first few months after the war, while politicians argued about who was in charge, local projects kept the health services running. Training schemes run by WHO helped ensure that there were enough people who knew how to keep epidemics under control. But, even though billions of dollars of resources were made available for the reconstruction efforts, in the first 6 months, only a tiny amount of money was coming into the country. Health services were therefore slow to come back. And without a surveillance system, there was no way to work out which populations were in most need. “We really lost an opportunity”, says Burkle.
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The new ministry

One year on, the situation is little better. But, says Naima Al Gaseer, WHO’s representative for Iraq, the pace of change seems to be increasing.

At the end of March, the Iraqi health ministry became the first of Iraq’s 26 government divisions to be granted full autonomy. Fradd says the handover was a positive step for his Iraqi colleagues.

Khudair Abbas, the Interim Health Minister, travelled down to Basra in person to deliver a letter waiving the requirement for central approval for the destruction of out-of-date drugs. But according to Fradd, Iraqi physicians and hospital bosses were reluctant to take this instruction on board. Although the standard process is arduous—involving committee meetings to decide on the drugs to be destroyed, and minutes from the meetings being sent to Baghdad for approval—hospital administrators feared that Abbas might soon be replaced by another minister with a penchant for bureaucracy.

As if to confirm their fears, a new minister, Ala’din Abdul Sahib Alwan, former WHO director of non-communicable diseases, was appointed at the begining of June. Before he went, however, Abbas—a surgeon who spent 20 years in exile in Britain—travelled to the World Health Assembly in Geneva in May, and laid out his plans for Iraq’s new health system.

Renovation of Iraq’s ageing infrastructure was top of the list. But Abbas also acknowledged the necessity for improving access to primary care—particularly child and maternal health services. He cited “impatience of the population after long suffering” as a significant challenge for the government to overcome, but security is undoubtedly the most pressing issue.

As a temporary measure, well-armed members of the “facility protection service” have been ordered to surround every hospital building; this at least seems enough to keep the looters out. It remains to be seen whether the new health minister will honour Abbas’ plans. The health ministry did not respond to The Lancet’s requests for an interview.

Improving Iraq’s health will be uphill struggle according to Nabil Amin, WHO’s Medical Officer for Iraq, who says Iraq’s infrastructure is “in dire need of rehabilitation”. He surveyed a sample of hospitals in Baghdad and found many had simply outlived their operating age. Recurrent problems with power supplies, water piping, and sewage systems cause further headaches.

Building projects completed under the CPA have improved conditions in some areas. But Amin says more work is urgently needed. The coalition authorities received harsh criticism for their focus on quantifiable targets, such as hospitals, clinics, medicines, and beds, in their plan for improving health. And according to Garfield, the new ministry still lacks a public health focus. “They are clinicians, not public health people”, he says.

Importantly, however, as Al Gaseer reports, the health ministry team seems keen to cooperate with NGOs. WHO is now working on a monitoring system for disease outbreaks in the country. Weekly reports are written at the district level, compiled at WHO’s office in Amman, Jordan, and transmitted to Baghdad for a monthly health update.

A real test for the new management will be handling the influx of refugees, who, according to UNHCR (the UN refugee agency) are choosing to return despite warnings about their safety. Peter Kessler, UNHCR spokesman, says only a tiny number of people were displaced in comparison with movements recorded after the 1991 Gulf War, in which 3 million people fled from the threat of Saddam’s retaliation. But even a few thousand returnees can overwhelm health services that are struggling to function. “The war was probably the least of Iraq’s problems, as we are seeing today”, says Kessler.

The main priorities for Iraq now are similar to what they were a year ago. Access to medicines is still a problem. US pre-war stockpiling of acute-care kits did little to aid the situation because what Iraqis need most are supplies for chronic diseases.

Garfield also believes better training for health workers is essential. “International organisations have tended to think Iraqis need basic training, but in fact they are fairly sophisticated”, he says. Much of the training organised during the past year has been too low a level to be of use.

Al Gaseer warns that the new ministry should keep one eye on the future. The psychological effects of the past 18 months’ insecurity and conflict will have colossal implications for the mental health of the nation. WHO has been working on services to help combat this inevitable burden, but preparation is understandably difficult with the country so unstable.

From his observations of Iraqi hospitals, Amin is concerned that the failure to crack down on tobacco use is storing up trouble for the future. Smoking prevalence is on the up and even hospitals are not designated smoke-free.

Burkle believes Iraq’s health problems teach us valuable lessons about coping after conflict. Public health must be the main focus, he says. But, this approach doesn’t necessarily mean prioritising hospital repairs. New buildings are of little use if security is so bad that people can’t leave their houses. Without adequate roads, health services are inaccessible. And drugs are important, but if hospitals are old and dirty, they will create more health problems than they cure. “Public health is understanding what’s leading to morbidity and mortality”, says Burkle. “And there really hasn’t been a public health approach.”

Hannah Brown”
?
Kirk:
I realize you blame everything on the president. You have no choice.

Right. Like I said there is no one else to blame.

“To do otherwise would force you to take a deep look into the mirror and admit you were wrong.”

So far I’ve given you a newspaper article, a direct link from the UN backing up that article regarding their involvement with the IAIS study on malnutrition in Iraq, and a thorough description of Iraq’s health situation from one of the most prestigious medical journals in the world. All you’ve given me is Brookings Institute - a right wing think-tank dedicated to spin. Therefore, I don’t feel I’m the one who needs to take a deep look in that mirror.

??

AP,

Are you saying that the shock and awe bombardment of Baghdad missed every single piece of infrastructure?

No, I am not saying that the bombing of Baghdad did not do some further damage to infrastructure. However, they did use guided munitions during the bombing of Baghdad so damage to infrastructure from the bombings would be limited.

how come they’re complaining that the infrastructure was better under Saddam?

Look at the information form the Brookings report. Iraqis say their standard of living is improving, their lives are better and they expect them to continue to improve. So, who is it that is saying infrastructure is worse?

Adrienne,

How old is this report from Lancet?

Judging from the references to the hand over of the authority to the Governing Council, coming summer and others, it would appear to me that this was written from information available in March or April 2004. That would make this information nearly 1 year old and would have been based on conditions roughly 1 year into the war.

I realize that conditions are not optimum. I never said they were. In fact I was responding to your statement below blaming everything on the president.

By not going in with enough troops the entire infrastructure of the country fell apart, and by not rebuilding it during the past two years they have done nothing but grow the insurgency, as well as an increasing desire among the average Iraqi citizen to see the backs of our troops.

The facts presented in the Brookings report, statements by USAID and Center for Strategic Studies all point to the fact that the Iraqi infrastructure was in shambles prior to the start of OIF. Now you post an article from Lancet that further disputes your statement.

A half-finished sewage treatment plant sits at the edge of the city, but construction stopped 7 years ago.

“The conditions are frankly third world”, he says. The buildings themselves—many almost 100 years old—are crumbling.

“The truth is, the central government had supplied them with very little for 3 years before the war”, explains Garfield.

physicians are struggling with outdated equipment

“The clinic has two x-ray machines, both built in the 70s”,

The war itself caused little damage to Iraq’s health infrastructure because troops were careful to spare essential buildings

Renovation of Iraq’s ageing infrastructure was top of the list

Nabil Amin, WHO’s Medical Officer for Iraq, who says Iraq’s infrastructure is “in dire need of rehabilitation”. He surveyed a sample of hospitals in Baghdad and found many had simply outlived their operating age.

I realize you blame everything on the president. You have no choice.
Right. Like I said there is no one else to blame.

How about laying the vast majority of blame in Sadam’s lap where it belongs. Even your Lancet report shows that Sadam had let Iraq’s infrastructure crumble while he built new palaces with the OFF money.

So far I’ve given you a newspaper article, a direct link from the UN backing up that article regarding their involvement with the IAIS study on malnutrition in Iraq,

The newspaper article that you admitted you were unable to find supporting data for and the UN link that was in essence a reprint of the newspaper article. Again with absolutely no supporting data.

I place greater credence with the Lancet article no doubt. However, again I question its age. I also have to look at who is quoted in the article. These are people who’s funding in many ways depends on how they make the situation appear. I find it telling that there are so many references to the infrastructure I have listed above combined with the statements such as those below listing improvements.

Some progress has been made towards rebuilding hospitals and securing medical supplies

But he concedes that Haveman’s dedication to securing a good working environment did enable health workers to actually get things done

But, says Naima Al Gaseer, WHO’s representative for Iraq, the pace of change seems to be increasing.

Building projects completed under the CPA have improved conditions in some areas.

Those with WHO and other health groups in Iraq see the devistation of the infrastructure caused by Sadam. They also see the efforts being made to improve that infrastructure by the administration and the coalition.