In the American Journal of Public Health June 2013 issue, “The Maladies of Water and War: Addressing Poor Water Quality in Iraq” explores water quality and availability throughout the 20th century in war-torn Iraq. The manuscript provides historical evidence of public health advances in Iraq around the 1950s, which become discarded and deteriorated later in the century as a result of war. To develop strategies on improving water quality in Iraq, scientifically relevant information was accrued and reviewed; these solutions may be used to improve water and reduce waterborne diseases in Iraq.
Countries surrounding the Persian Gulf include Oman, United Arab Emirates, Iran, Iraq, Bahrain, Saudi Arabia, Kuwait, and Qatar. These countries were historically low to middle income, or developing countries, before oil was discovered. After economic stimulation from the oil boom, the majority of the countries shifted to a high income status and became developed countries. One country was different.
A child cries as a woman fills pans of water from a public water hose on open ground in Najaf, Iraq, in 2006. Alla al-Marjani/Associated Press.
Oil was discovered in 1927 in Iraq; the petroleum industry and agriculture formed the platform for Iraq’s economy. The stable economy promoted developed healthcare and public health interventions to the Iraqi population. Healthcare began in Iraq in the 1920s and continued to develop until around the 1950s. Iraq was economically strong and powerful before any other country surrounding the Persian Gulf and would have been historically considered a developed country at the time.
Unlike any other country around the Persian Gulf, public health organizations began developing early in the century; the Ministry of Health in Iraq was established in 1939. The Ministry of Health was responsible for development of public health measures, medical care facilities, and health services. In 1952, the organization switched to be under the control of the Director General of Health, which ensured increased breadth of jurisdiction. Curative medicine and preventative and social medicine divisions were created in order to divide major issues. Social medicine departments focused on sanitation, endemic diseases, vital statistics, and disease registration, while the Director of Curative Medicine supervised hospitals, dispensaries, rural health, laboratories, and medical stores. General public health measures were supervised under the Ministry of Education; nutrition, meat and dairy inspection services were inspected by the Ministry of Economics veterinarian service. Many voluntary agencies provided support for large-scale public health issues. The Children’s Welfare society promoted maternal and child health, the Red Crescent Society supported education and child health centers, the Anti-Tuberculosis Society developed interventions against tuberculosis, and the Reformed Church of American maintained a medical mission, as well as, founded leper colonies.
Superior levels of health standards and accessibility to healthcare were achieved mid-century throughout Iraq. 82 civilian hospitals were operating in Iraq in 1950. 534 out of 4,901 beds were located in Basrah. Free medical care was provided in over 90 percent of the available beds. The Royal Hospital, located in Baghdad, was equipped with medical, surgical, pediatric, and infectious disease specialty areas. Maternity and pediatric care were incorporated into many of the general hospitals; additionally, six isolation, three ophthalmic, two venereal disease, two child welfare, three maternity and children’s, one mental, and leper hospitals were all available. 433 dispensaries were also available, of which 403 belonged to the government health services.
" Over the span of one century, Iraq transformed from a developed country to developing country. "
The progression of health services thrived and continued to build in Iraq. In 1954, the Iraqi government, in conjunction with the World Health Organization and the United Nations International Children’s’ Emergency Fund, created a training center which focused on training local medical personnel on the principles of maternal and child health. Laboratories were systematically operated throughout the country in order to confirm disease diagnosis and apply appropriate treatment plans. Central laboratory facilities were all located in Baghdad; these labs not only focused on diagnosing diseases, but applied research to medicine and public health issues, as well. Research laboratories worked on a variety of issues, including malaria control program, manufacturing smallpox vaccinations, and analyzing food, water, and milk from agricultural and industrial preparation facilities. The Royal College of Medicine, one of the first medical schools in the Middle East, was founded in 1927. In 1950, 811 registered physicians were associated with hospitals in Iraq. The physician-population ratio was very high in the cities, averaging 55 to 70 physicians per 100,000 person population. Rurally, there were approximately four to six physicians per 100,000 person population. Additional staff was present throughout Iraq; 497 nurses, 72 dentists, numerous midwives, 69 pharmacists, 236 health officials and or medical assistants, and 341 vaccinators were employed by the government or worked with private practice.
Later in the century, the progression was halted and began to collapse. Over the span of one century, Iraq transformed from a developed country to developing country. Iraq took part in war after war including World War I, World War II, and the Persian Gulf wars in all three phases: 1980 to 1988, 1988 to 1991, and 2003 to 2010. The effects of the war on Iraq shifted the focus from providing Iraqis with access to healthcare and public health services to having access to basic human necessities.
Timeline of Wars in Iraq
Near the end of the 20th century, after suffering from the accumulation of damage from the wars, only a few hospitals remained in operation. Medical and general supply shortages were experienced throughout the country. Iraq’s infrastructure was deteriorated and the destruction of Iraq’s water supply system caused water purification and sewage system failure. Access to healthcare declined and diseases proliferated.
From 1990 to 2010, a significant amount of waterborne disease cases occurred in Iraq. In only five years, from 2005-2010, 4,697 cholera cases, 36,208 typhoid cases occurred, and 548,204 gastrointestinal disease were reported. Diarrhea was the leading cause of death in infants (49.8 percent) from 1994 to 1999. Vector-borne diseases, primarily schistomiasis and malaria, were commonly reported.
Today, poor water quality and waterborne diseases continue to exist in Iraq. Improvements have been attempted in the past, but have not been sustained and have failed. Sanitary conditions in hospitals remain unsatisfactory, trained personnel are largely absent, medical supplies continue to be unavailable, and rural populations generally lack access to healthcare. Infectious diseases frequently occur from poor sanitation, limited access to clean water, and inadequate public health awareness and education. These deficiencies contribute to the deteriorating health of the Iraqi population.
Unreliable drinking water and sanitation in Iraq. Reference: Inter-Agency Information and Analysis Unit. Water in Iraq fact sheet. 2011. Accessed April 9, 2012.
Solutions addressing the water crises and waterborne disease prevalence in Iraq must encompass a myriad of factors. Positive changes must be made in order to transform the country and eliminate waterborne disease outbreaks. A top down approach to water quality reconstruction must occur in Iraq in order to confirm sustainable and long-lasting solutions. Reform approaches must occur not only on a country-wide scale, but on an individual level as well. The first step is to rebuild public health infrastructure, the second step is to provide water resource management of water treatment facilities (re-mineralize desalination plants), and lastly, point of use water treatment can be used by each person to address current poor water quality.
The Iraqi population has suffered from countless wars that have directly and indirectly exacerbated long-standing waterborne diseases issues. Significant, sustainable solutions addressing waterborne diseases require public health interventions, improvements to access of potable water, monitoring and evaluation systems, and point of use treatment and educational interventions. These long-term solutions to change water in Iraq have the potential to provide individual access to clean water, alleviate interrelated cycles of health disparities, and promote health and well-being throughout the country.