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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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