Sanctions and childhood mortality in Iraq

A bibliometric analysis of global research on united nations security council sanctions (1990-2023)

UNSC sanctions have been referred to as a powerful tool increasingly used by the UNSC to maintain international peace and security based on Chapter VII of the United Nations Charter. This study conducts a bibliometric analysis to provide a comprehensive overview of the current research status, developments trends, and research hotspots in UNSC sanctions research from 1990 to 2023. This study uses CiteSpace to visualize and analyze datasets of 345 articles about UNSC sanctions obtained from the Web of Science (WOS) database. The research on UNSC sanctions has three stages: the initial development stage (1990-2006), the transitional development stage (2007-2017), and the rapid development stage (2018-2023). This study describes UNSC sanctions research status, trends, hotspots, and distributions of publications by journal sources, disciplines, countries, institutions, and authors. It also describes the knowledge-based mapping and research hotspots on UNSC sanctions, including keywords, citation burst, keyword clusters, keyword clusters timeline view, cited references, intellectual base, and descriptive analysis. In addition, this study analyzed UNSC sanctions research divided into four domain categories: implementation, human rights, impacts, and specific regimes. The results showed that the topic of UNSC sanctions was multidisciplinary research and that scholars from different research disciplines had different focuses on UNSC sanctions. This study offers valuable insights into the current hot topics within the field of UNSC sanctions and offers recommendations for future research directions.

Economic sanctions and spread of infectious diseases

Economic sanctions can induce economic crises and compromise the determinants of health. In the literature, economic crises have been found to increase the risk of infectious disease outbreaks. Presumably, sanctions can increase the risk of infectious disease spreads, indirectly. However, non-economic factors can fuel the adverse impact of sanctions, including political consequences of sanctions and civil war. We performed a systematic literature review of articles in Embase, MEDLINE, Scopus, Web of Science, Cochrane Library, and the grey literature to assess empirically the impact of economic sanctions on the spread of infectious diseases within and beyond the borders of sanctioned countries. Our review did not identify any study meeting our inclusion criteria. Most of the studies did not control for major socio-political events, particularly armed conflicts in the sanctioned countries. This discovery underscores a notable gap in the examination of the impact of economic sanctions on the propagation of infectious diseases, presenting a threat to global health. Using the social-ecological model, we hypothesize how the economic crisis resulting from economic sanctions affects determinants of health, increases the risk of the spread of infectious diseases and hinders the response capacity of health systems.

Sanctions and economic growth: Do sanction diversity and level of development matter?

The application of economic and political sanctions becomes a vital tool of international politics to facilitate peaceful coexistence among the nations. However, the issue of the effectiveness of sanctions in creating adequate disutility to ensure compliance remains contentious. Therefore, this study assesses the effect of sanctions on the economic growth of the target states. It captures the diversity of sanctions using system Generalized Method of Moments (GMM) with extensive dataset for the period 1970-2018. The findings reveal that extensive, multilateral sanctions, and export restriction are the only sanction categories that are effective in creating disutility and reducing the real income per capita growth when targeted at the developed countries. On the other hand, limited sanctions (partial embargo) - sanctions that are targeted at specific sectors, groups, and issues such as withdrawal of foreign aid, as well as import restrictions can effectively reduce income per capita growth when imposed on developing countries while all other categories of sanctions have a positive effect on income growth in targeted developing economy. Therefore, we, conclude that the sanctions diversity, development level of the target country and sender identity play vital roles concerning the sanctions-economic growth nexus. These attributes should be considered in the application and analyses of sanctions to ensure their effectiveness. The study provided several interesting policy insights.

The impact of economic sanctions on health and health systems in low-income and middle-income countries: a systematic review and narrative synthesis

INTRODUCTION

Economic sanctions restrict customary commercial and financial ties between states to induce change in political constitution or conduct of the targeted country. Although the stated goals of sanctions often include humanitarian objectives, prospective procedures for health risk assessment are not regularly incorporated in their implementation. Moreover, past experience suggests that the burden of economic isolation may fall on the civilian population. We present key findings from a WHO-sponsored evidence review on the impact of economic sanctions on health and health systems in low-income and middle-income countries, aiming at comprehensive coverage and explicit consideration of issues of causality and mechanisms.

METHODS

Broad searches of PubMed and Google Scholar (1970-2021) were designed to retrieve published and grey English-language literature expected to cut across disciplines, terminology and research methods. Studies providing an impact estimate were rated by a structured assessment based on ROBINS-I risk of bias domains, synthesised via vote counting and contextualised into the broader literature through a thematic synthesis.

RESULTS

Included studies (185) were mostly peer-reviewed, mostly single-country, largely coming from medicine and public health, and chiefly concerned with three important target countries-Iraq, Haiti and Iran. Among studies providing impact estimates (31), most raised multiple risk-of-bias concerns. Excluding those with data integrity issues, a significant proportion (21/27) reported consistently adverse effects of sanctions across examined outcomes, with no apparent association to assessed quality, focus on early episodes or publication period. The thematic synthesis highlights the complexity of sanctions, their multidimensionality and the possible mechanisms of impact.

CONCLUSION

Future research should draw on qualitative knowledge to collect domain-relevant data, combining it with better estimation techniques and study design. However, only the adoption of a risk assessment framework based on prospective data collection and monitoring can certify claims that civilians are adequately protected.

The Violence of Non-Violence: A Systematic Mixed-Studies Review on the Health Effects of Sanctions

The use of sanctions as a policy tool to affect change in the political behavior of target states has increased over the past 30 years, along with a concern about their impact on civilian health. Some researchers have proposed that targeting sanctions can avoid their moral costs, yet others have challenged this claim. This systematic mixed-studies review explored the debate about targeted sanctions by appraising their health effects as reported in the medical and public health literature, with a global focus and through the COVID-19 era.We searched three electronic databases without temporal or geographical restrictions and identified 50 studies spanning three decades (1992-2021) meeting our inclusion criteria. Using a piloted form, we extracted quotations addressing our research questions and identified themes that we grouped according to the effects of sanctions on health or its determinants, generating frequency distributions to assess the strength of support for each theme. While no study posited a causal relationship between sanctions and health, or engaged the morality of sanctions, most implied that when sanctions were present, health was inevitably impacted, even for sanctions ostensibly targeted to minimize civilian harm. Our findings suggest that given the integrated nature of the global economy, it is all but impossible to design sanctions that will achieve their stated goals without inflicting significant harm on civilians. We conclude that the use of sanctions as a policy tool threatens global health and human rights, especially in times of crises.

Economic Sanctions and Regional Differences: Evidence from Sanctions on Russia

The objective of this study was to analyze the relationship between economic sanctions and regional differences within Russia from three perspectives: regional favoritism of the political elite, industry development, and trade costs. Using the nighttime lights in Russia, we found a correlation between economic sanctions and regional differences. First, as sanctions increased, the lights of Moscow, St. Petersburg, and provincial capitals were brighter than those of the rest of the country. Second, the lights of manufacturing cities were brighter as sanctions increased. However, under the influence of sanctions, the lights of mining areas of Russia were dimmer than those of other areas. Finally, there were relatively more economic activities in areas close to the Chinese border. The lights of Blagoveshchensk were brighter than that of the rest of the country. In addition, the relationship between economic sanctions and the brightness of lights had the characteristics of stages. There was a negative correlation with the brightness of Russian lights in the early stages of economic sanctions. However, this negative correlation disappeared in the later stages.

Economic Sanctions and Environmental Performance: The Moderating Roles of Financial Market Development and Institutional Quality

This article examines the impacts of cross-border economic sanction (CES) on environmental performance by using the structural gravity model for 207 target countries during the 1995-2018 period. We consider various forms of sanction, including arms, military, trade, finance, travel, and others, while the environmental performance index (EPI) is used to measure the environmental performance. The results reveal that the imposition of a sanction, especially arm, financial, travel, and other sanctions has a significantly negative effect on the EPI score. The effects are also largely heterogeneous across sanctioned countries in terms of their economic development. The negative impact of sanctions on the environmental performance is found the most evident in developing transition countries, followed by developed economies but insignificant if the target is a developing nation. Furthermore, the properties of the financial market and the institutional quality of the sanctioned states critically affect the relationship between CES and EPI. Particularly, either the better financial market and institution development, the high degree of financial openness, central bank independence, or well-developed institutional quality helps target countries mitigate the consequences of CES on EPI. The empirical findings provide insightful implications about the socially responsible aspect of sanctions and vital lessons for economists and policymakers in the target countries in reducing the environmental costs of sanctions.

Sociodemographic Determinants of Healthcare-Seeking Options and Alternative Management Practices of Childhood Diarrheal Illness: A Household Survey among Mothers in Iraq

Diarrhea remains a significant cause of child morbidity and mortality in Iraq. The objective of this study was to examine the current practices of home-based management of diarrheal illnesses among Iraqi children. We surveyed mothers of children aged less than 5 years to identify the sociodemographic factors associated with maternal healthcare-seeking practices. A total of 500 mother-child pairs were interviewed in a cross-sectional household survey in Thi-Qar Governorate, southeastern Iraq, between March 2016 and February 2017. Logistic and multinomial regression models were used to infer sociodemographic predictors of the healthcare-seeking and alternative management practices adopted by the mothers. The interviewees reported that 35.2% of their children had diarrhea in the 2 weeks before the survey. The least likelihood of reported occurrence of diarrhea was among mother-child pairs where the mothers had received university education, as compared with mothers who were illiterate or received only primary or secondary education. Lower odds (odds ratio = 0.4, P-value < 0.001) of reported childhood diarrhea was revealed among mothers aged > 25 years than among those younger. Self-ordered medicine from a pharmacy was the most preferred alternative management option in almost half (52.4% [262/500]) of the interviewed mothers in Thi-Qar. Interestingly, 69.6% (348/500) of the mothers reported supplying their children suffering from diarrhea with antibiotics. Relative to mothers with university education, those with high school education had more likelihood of selecting medical center (relative risk ratio [rrr] = 2.4) and pharmacy (rrr = 3.7) as against no treatment. Lower maternal educational level, mothers' age < 25 years, and the district of residence were important factors associated with diarrhea occurrence among children younger than 5 years. In light of the findings from this study, intervention aimed at improving healthcare seeking for managing diarrhea in Iraqi children should jointly consider the influence of mothers age, education, as well as the level of economic status of the communities in which mothers of these children reside. The results of this study indicate the need for enhancing public health education to improve the maternal management of diarrheal disease and the avoidance of unnecessary use of antimicrobials.

Iran, sanctions, and the COVID-19 crisis

With an over 80 million population, Iran is the second-largest country in the Middle East. The coronavirus disease 2019 (COVID-19) has spread over all 31 provinces of Iran, leading to the most cases and death among the Eastern Mediterranean countries. At the same time, Iran is under the United States political and economic sanctions that compromised Iran's health system. Although medicines and basic medical equipment exempted from the economic sanctions, direct and indirect effects of sanctions have restricted Iran's banking system, and consequently has led to a wide range of limitation on trade, manufacturing sector, insurance and ventures. All these circumstances have meant that Iran is restricted to provide the essential basic medical equipment for diagnosis, treatment and prevention of the COVID-19. Although sanctions are not the sole reason for this high rate of mortality and morbidity in a short time period, the chronic and long-term effects of sanctions may be more tangible than their acute impact. In conclusion, providing health services is one of the major problems of Iran's health system during this pandemic that potentially influence on morbidity and mortality of the COVID-19. Iran needs to be free from sanctions for battling against this crisis.Key messagesIran is one of the countries that significantly impacted by the COVID-19 pandemic.Iran is under political and economic sanctions that consequently influence on their health system during the COVID-19 crisis.The chronic and long-term effects of sanctions may be more tangible than their acute impact.

Alcohol: from Mesopotamia to Modern Iraq

An understanding of alcohol's place in Iraq's history and society can help inform alcohol policy responses in that country and other Muslim majority countries. This article describes the history of alcohol in Iraq from ancient to modern times, with reflection on the challenges facing Iraqi youth today. A search was undertaken to identify peer-reviewed and gray literature that describes alcohol-related practices, norms, and values across the millennia in Iraq. A historical overview is provided of alcohol's use and context, with more detail on recent times. Alcohol was an important commodity in Iraq until the rise of Islam in the seventh century CE. Despite the subsequent Islamic restrictions on alcohol, alcohol remained present in Iraq's society and cultures. Recent studies provide varying descriptions of the prevalence of alcohol consumption, and there are challenges in researching this sensitive topic. External forces shaping alcohol use in Iraq include direct and indirect alcohol promotion, globalized media, and conflict and violence with its associated stress and trauma. Alcohol research and policy development in Iraq must consider the country's unique cultural, religious, historical, and political context. Iraq's youth may be subject to pressures to increase consumption, and thus policies must be informed by an understanding of the complex set of current perspectives and pressures.

War or health: a four-decade armed conflict in Iraq

Iraq has suffered 40 years of continual conflict, with large-scale traumatic events including successive wars, economic sanctions, sectarian conflict, terrorism, and organized crime. Population health and the health systems and other services and infrastructure that support a population's health usually suffer severe consequences in conflict-affect countries and Iraq has been no exception. In this article we aim to provide a historical narrative of the four decades of successive wars in Iraq and present some of the consequences of this particular situation of persistent violence and how it has reflected on the health status of the Iraqi people, as indicated by increasing morbidity, mortality, injuries, mental health problems and displacement. Continutation of the current situation of insecurity is anathema for health as war and health can never be compatible, it is a choice between war or health.

Changing views on child mortality and economic sanctions in Iraq: a history of lies, damned lies and statistics

In August 1990, Saddam Hussein's army invaded Kuwait and consequently the United Nations imposed economic sanctions on Iraq. In 1991, an international military alliance expelled the Iraqi army from Kuwait during a short war. Nevertheless, the economic sanctions remained in place-their removal required that Iraq should destroy its weapons of mass destruction. Subsequent years saw reports of acute suffering in Iraq. The sanctions undoubtedly greatly reduced the country's ability to import supplies of food and medicine. Particular concerns arose about the state of young children. These concerns crystalised in 1999 when, with cooperation from the Iraqi government, Unicef conducted a major demographic survey. The results of the survey indicated that the under-5 death rate in Iraq had increased hugely between 1990 and 1991 and had then continued at a very high level. The survey results were used both to challenge and support the case for the invasion of Iraq in 2003. And they were cited by Tony Blair in 2010 in his testimony to the Iraq Inquiry established by the British government. Indeed, the results of the 1999 Unicef/Government of Iraq survey are still cited. Since 2003, however, several more surveys dealing with child mortality have been undertaken. Their results show no sign of a huge and enduring rise in the under-5 death rate starting in 1991. It is therefore clear that Saddam Hussein's government successfully manipulated the 1999 survey in order to convey a very false impression-something that is surely deserving of greater recognition.

(Dis)connectivities in wartime: The therapeutic geographies of Iraqi healthcare-seeking in Lebanon

The proliferation of conflicts across borders of Middle Eastern States has transformed the landscapes of health and healthcare across the region. In the case of Iraq, state healthcare has collapsed under the strain of protracted conflicts. Meanwhile, Lebanon's post-war healthcare system is booming, and becoming more privatised. In this paper, we build on an ethnographic study on the movements and experiences of Iraqi patients in Lebanon to show how one of the consequences of war is the rise of alternative forms of healthcare-seeking practices and survival strategies - a therapeutic geography that is embedded in regional economies and geopolitical relations and reconfigurations. We argue for the need to reimagine the disconnectivity and connectivity of healthcare systems under war and conflict as grounded in the empirical realities and experiences of mobility in the Middle East.

Trade in medicines and the public's health: a time series analysis of import disruptions during the 2015 India-Nepal border blockade

BACKGROUND

Nepal was struck by devastating earthquakes in April-May 2015, followed by the India-Nepal border blockade later that year.

METHODS

We used the United Nations Commodity Trade Statistics (UN Comtrade) database to analyse exports of various health commodities from India to Nepal from January 2011-September 2016. We used time-series regressions of trading volume vs. unit price to ask how well Nepal's trading history with India prior to the earthquake and blockade was able to predict unit prices of health commodities imported into Nepal during and after the earthquake and the blockade. Regression residuals were used to quantify the extent to which the blockade impacted the price of healthcare commodities crossing into Nepal.

RESULTS

During the blockade period (September 2015-early February 2016), the volume of all retail medicines traded across the India-Nepal border was reduced by 46.5% compared to same months in 2014-2015. For medical dressings, large volumes were exported from India to Nepal during and shortly after the earthquakes (May-June 2015), but decreased soon thereafter. During the earthquake, the difference between observed and predicted values of unit price (residuals) for all commodities show no statistical outliers. However, during the border blockade, Nepal paid USD 22.3 million more for retail medicines than one would have predicted based on its prior trading history with India, enough to provide healthcare to nearly half of Kathmandu's citizens for 1 year.

CONCLUSION

The India-Nepal blockade was a geopolitical natural experiment demonstrating how a land-locked country is vulnerable to the vagaries of its primary trading partner. Although short-lived, the blockade had an immediate impact on traded medicine volumes and prices, and provided a large opportunity cost with implications for public health.

A Novel Method for Verifying War Mortality while Estimating Iraqi Deaths for the Iran-Iraq War through Operation Desert Storm (1980-1993)

Objectives

We estimated war-related Iraqi mortality for the period 1980 through 1993.

Method

To test our hypothesis that deaths reported by siblings (even dating back several decades) would correspond with war events, we compared sibling mortality reports with the frequency of independent news reports about violent historic events. We used data from a survey of 4,287 adults in 2000 Iraqi households conducted in 2011. Interviewees reported on the status of their 24,759 siblings. Death rates were applied to population estimates, 1980 to 1993. News report data came from the ProQuest New York Times database.

Results

About half of sibling-reported deaths across the study period were attributed to direct war-related injuries. The Iran-Iraq war led to nearly 200,000 adult deaths, and the 1990–1991 First Gulf War generated another approximately 40,000 deaths. Deaths during peace intervals before and after each war were significantly lower. We found a relationship between total sibling-reported deaths and the tally of war events across the period, p = 0.02.

Conclusions

We report a novel method to verify the reliability of epidemiological (household survey) estimates of direct war-related injury mortality dating back several decades.

Use of complementary and alternative medicine in pregnancy: a cross-sectional survey on Iraqi women

BACKGROUND

Due to the lack of strong evidence on safety and efficacy of complementary and alternative medicine (CAM) approaches, the use of CAM in women during pregnancy could be hazardous for mother and fetus. Meanwhile, little is known regarding the patterns, the reasons and the factors affecting use of CAM among pregnant women in Iraq.

METHODS

A cross sectional survey design was used to carry out face-to-face interviews with 335 consecutive pregnant women. The questionnaire comprised of three sections: socio-demographic characteristics, pregnancy-related aspects and the patterns and attitudes towards use of CAM. Determinants of CAM use were assessed through the logistic regression analysis.

RESULTS

Three hundred thirty-five pregnant women completed the questionnaire. 56.7 % reported using at least one form of CAM modalities. In total, 24 different types of CAM were used; with herbal medicine (53.7 %) and multivitamins (36.3 %) the most commonly used modalities. From the logistic regression analysis, the variables positively associated with CAM use were: rural residence (odds ratio (OR) 2.0, p < 0.01), no occupation (OR 2.7, p < 0.05), high income (OR 2.0, p < 0.05), perceived healthy status (OR 2.6, p < 0.05) and ever use of contraception (OR 2.0, p < 0.01). Only 0.5 % of CAM users disclosed their CAM use to physicians.

CONCLUSIONS

The proportion of CAM users among pregnant women is relatively high and it is important to learn what types of CAM they use. However, disclosure of CAM use was extraordinarily low. Given the low rate of disclosure, it should be ensured that physicians establish good level of communication with pregnant women and have adequate knowledge of CAM.

The effects of economic sanctions on disease specific clinical outcomes of patients with thalassemia and hemophilia in Iran

BACKGROUND

The sanctions applied by both the USA and the EU against Iran do not formally ban the exports of medicines; in practice, however, patients are experiencing great difficulty in securing the treatment. This article documents the impact of international sanctions on patients with thalassemia and hemophilia in southern Iran.

METHODS

This survey examined the specific effects of external sanctions on the access of patients to their treatment between 2009 and 2012 from the point of view of patients with thalassemia (n=69) and congenital coagulation disorders (n=40) as well as related physicians (n=20). Also, clinical manifestation and laboratory data of patients were compared in the same period.

RESULTS

Access to deferoxamine and Exjade as iron chelators in patients with thalasseamia, respectively, declined by almost 70% and half over this period. In addition, access to lyophilized coagulation factor VIII concentrate in hemophilia A dramatically dropped from 96.7% in 2009 to 3.3% in 2012. The clinical results showed a significant deterioration of arthropathy (P<0.001) in hemophiliac patients and a significant increase in serum ferritin levels in thalassemia patients (P=0.036).

CONCLUSION

Sanctions had significant effect on public health on patients with thalassemia and hemophilia.

The intergenerational effects of war on the health of children

BACKGROUND

The short- and medium-term effects of conflict on population health are reasonably well documented. Less considered are its consequences across generations and potential harms to the health of children yet to be born.

DISCUSSION

Looking first at the nature and effects of exposures during conflict, and then at the potential routes through which harm may propagate within families, we consider the intergenerational effects of four features of conflict: violence, challenges to mental health, infection and malnutrition. Conflict-driven harms are transmitted through a complex permissive environment that includes biological, cultural and economic factors, and feedback loops between sources of harm and weaknesses in individual and societal resilience to them. We discuss the multiplicative effects of ongoing conflict when hostilities are prolonged.

SUMMARY

We summarize many instances in which the effects of war can propagate across generations. We hope that the evidence laid out in the article will stimulate research and--more importantly--contribute to the discussion of the costs of war; particularly in the longer-term in post-conflict situations in which interventions need to be sustained and adapted over many years.

Governance and health in the Arab world

Since late 2010, the Arab world has entered a tumultuous period of change, with populations demanding more inclusive and accountable government. The region is characterised by weak political institutions, which exclude large proportions of their populations from political representation and government services. Building on work in political science and economics, we assess the extent to which the quality of governance, or the extent of electoral democracy, relates to adult, infant, and maternal mortality, and to the perceived accessibility and improvement of health services. We compiled a dataset from the World Bank, WHO, Institute for Health Metrics and Evaluation, Arab Barometer Survey, and other sources to measure changes in demographics, health status, and governance in the Arab World from 1980 to 2010. We suggest an association between more effective government and average reductions in mortality in this period; however, there does not seem to be any relation between the extent of democracy and mortality reductions. The movements for changing governance in the region threaten access to services in the short term, forcing migration and increasing the vulnerability of some populations. In view of the patterns observed in the available data, and the published literature, we suggest that efforts to improve government effectiveness and to reduce corruption are more plausibly linked to population health improvements than are efforts to democratise. However, these patterns are based on restricted mortality data, leaving out subjective health metrics, quality of life, and disease-specific data. To better guide efforts to transform political and economic institutions, more data are needed for health-care access, health-care quality, health status, and access to services of marginalised groups.

Women's views and experiences of antenatal care in Iraq: a Q methodology study

Background

Understanding women’s experiences and perspectives of antenatal care services is particularly critical for enhancing effectiveness of services delivery and addressing women’s needs and expectations. As part of a comprehensive assessment of the maternity care services in Iraq, this study aimed to explore the views and experiences of antenatal care in a sample of women.

Methods

This explorative study was conducted in Erbil governorate, Iraq. Data were collected using Q methodology, a technique for eliciting subjective views and identifying shared patterns among individuals. A sample of 38 women of different educational and socioeconomic statuses were invited to sort a set of 39 statements reflecting different aspects of the available antenatal care services and issues related to their last pregnancies into a distribution on a scale of nine from “disagree most” to “agree most”. By-person factor analysis was used to derive latent views through centroid factor extraction and varimax rotation of factors.

Results

Analysis of the participants’ Q sorts resulted in identifying four distinct views and experiences of pregnancy and antenatal care services: (i) public maternity services second best: preference for, and ability to afford, private care, (ii) dissatisfaction with public maternity services: poor information sharing and lack of health promotion, (iii) satisfaction with public maternity service but information gaps perceived and (iv) public maternity services second best: preference for private care but unaffordable. The typical characterizations that were associated with each view were highlighted.

Conclusions

This study revealed different patterns of views and experiences of women of pregnancy and antenatal care services and recognized the particular issues related to each pattern. Different patterns and types of problems and concerns related mainly to inadequate provision of information and poor interpersonal communication, poor utilization of public services and a general preference to use private services were identified in the different groups of women.

Using Q-methodology to explore people's health seeking behavior and perception of the quality of primary care services

Background

Information on health seeking behavior and beneficiaries’ perception of the quality of primary care can help policy makers to set strategies to improve health system. With scarcity of research on this particular field in Iraqi Kurdistan region, we sought to explore the patterns of health seeking behavior and perception of the quality of primary care services of a sample of population.

Methods

This explorative study was carried out in Erbil governorate, Iraq. Data were collected using the novel approach of Q-methodology for eliciting subjective viewpoints and identifying shared patterns among individuals. Forty persons representing different demographic and socioeconomic groups and living in different areas of Erbil governorate sorted 50 statements reflecting different aspects of health-seeking behavior and primary care services into a distribution on a scale of nine from “disagree most” to “agree most”. By-person factor analysis through centroid factor extraction and varimax rotation of factors were used to derive latent viewpoints.

Results

Four distinct patterns of health seeking behavior and viewpoints toward the primary care services were identified. People in factor 1 are extremely critical of the services at primary health care centers and are regular users of the private health sector. People in factor 2 positively recognize the services at primary health care centers but mainly turn to inappropriate health seeking behavior. People in factor 3 have satisfaction with the services at primary health care centers with minimal use of these services, but mainly turn to the private sector. People in factor 4 are slightly satisfied with the services at primary health care centers but mainly rely on these services.

Conclusions

This study highlighted the typical characterizations that were associated with each uncovered factor. Informing on the beneficiaries’ concerns about the primary care services can help to improve the system through further exploring the issues raised by the respondents and directing particular action on these issues. The characterizing and distinguishing statements can be used as a set of questions to conduct community-based survey on this important aspect of health services.

The range and diversity of providers' viewpoints towards the Iraqi primary health care system: an exploration using Q-methodology

Background

The increasingly recognized need for reorganizing the primary health care services in Iraq calls for a comprehensive assessment of the system to better understand its problems and needs for development. As part of such comprehensive assessment and due to the important role of primary health care providers in adopting any change, we ought to explore the range and diversity of viewpoints of primary health care providers towards the Iraqi primary health care system.

Methods

This explorative study was carried out in Erbil governorate, Iraq from May to July 2011. Data were collected from primary health care providers using Q-methodology to elicit subjective viewpoints and identify shared patterns among individuals. Forty primary health care providers representing eight primary health care centers sorted 41 statements reflecting different aspects of the Iraqi primary health care system into a distribution on a scale of nine from “disagree most” to “agree most”. By-person factor analysis was used to derive latent viewpoints through centroid factor extraction and varimax rotation of factors.

Results

Analysis of the participants’ Q-sorts resulted in four distinct viewpoints among primary health care providers toward the current primary health care system. One factor emphasized positive aspects of the current primary health care system that is content with the current primary health care system. The other three factors highlighted the negative aspects and they included (i) professionally-centered viewpoint, (ii) comprehensive perception and problem-based solutions and (iii) critical to leadership/governance aspects of the system.

Conclusions

This study revealed diverse viewpoints of primary health care providers toward the current Iraqi primary health care system and recognized the particular issues related to each viewpoint. The findings can contribute to a better understanding of health policy makers and primary health care managers concerning the problems facing the primary health care system that might contribute to change in the management of this system.

Syria: effects of conflict and sanctions on public health

The past 18 months have witnessed considerable turmoil in countries of the MENA region. The Syrian Arab Republic (SAR) is one such country, currently in the midst of a civil war. This report draws attention to some of the recent achievements of its health services, where, despite a dearth of published materials, the country achieved remarkable declines in maternal mortality and infant mortality rates. Its health sector now faces destruction from on-going violence compounded by economic sanctions that has affected access to health care, to medicines and to basic essentials as well as the destruction of infrastructure. This paper draws attention to the achievements of the country's health services and explores some of the consequences of conflict and of sanctions on population health. Readers need to be mindful that the situation on the ground in a civil war can alter on a daily basis. This is the case for Syria with much destruction of health facilities and increasing numbers of people killed and injured. We retain however our focus on the core theme of this paper which is on conflict and on sanctions.

Iraqi primary care system in Kurdistan region: providers' perspectives on problems and opportunities for improvement

BACKGROUND

As part of a comprehensive study on the primary health care system in Iraq, we sought to explore primary care providers' perspectives about the main problems influencing the provision of primary care services and opportunities to improve the system.

METHODS

A qualitative study based on four focus groups involving 40 primary care providers from 12 primary health care centres was conducted in Erbil governorate in the Iraqi Kurdistan region between July and October 2010. A topic guide was used to lead discussions and covered questions on positive aspects of and current problems with the primary care system in addition to the priority needs for its improvement. The discussions were fully transcribed and the qualitative data was analyzed by content analysis, followed by a thematic analysis.

RESULTS

Problems facing the primary care system included inappropriate health service delivery (irrational use of health services, irrational treatment, poor referral system, poor infrastructure and poor hygiene), health workforce challenges (high number of specialists, uneven distribution of the health workforce, rapid turnover, lack of training and educational opportunities and discrepancies in the salary system), shortage in resources (shortage and low quality of medical supplies and shortage in financing), poor information technology and poor leadership/governance. The greatest emphasis was placed on poor organization of health services delivery, particularly the irrational use of health services and the related overcrowding and overload on primary care providers and health facilities. Suggestions for improving the system included application of a family medicine approach and ensuring effective planning and monitoring.

CONCLUSIONS

This study has provided a comprehensive understanding of the factors that negatively affect the primary care system in Iraq's Kurdistan region from the perspective of primary care providers. From their experience, primary care providers have a role in informing the community and policy makers about the main problems affecting this system, though improvements to the health care system must be taken up at the national level and involve other key stakeholders.

Iraqi health system in kurdistan region: medical professionals' perspectives on challenges and priorities for improvement

BACKGROUND

The views of medical professionals on efficiency of health system and needs for any changes are very critical and constitute a cornerstone for any health system improvement. This is particularly relevant to Iraqi Kurdistan case as the events of the last few decades have significantly devastated the national Iraqi health system while the necessity for adopting a new health care system is increasingly recognized since 2004. This study aims to examine the regional health system in Iraqi Kurdistan from medical professionals' perspectives and try to define its problems and priorities for improvement.

METHODS

A survey questionnaire was developed and administered to a convenience sample of 250 medical professionals in Erbil governorate. The questionnaire included four items; rating of the quality of services and availability of resources in the health institutions, view on different aspects of the health system, the perceived priority needs for health system improvement and gender and professional characteristics of the respondents.

RESULTS

The response rate to the survey was 83.6%. A high proportion of respondents rated the different aspects of services and resources in the health institutions as weak or very weak including the availability of the required quantity and quality of medicines (68.7%), the availability of sufficient medical equipment and investigation tools (68.7%), and the quality of offered services (65.3%). Around 72% of respondents had a rather negative view on the overall health system. The weak role of medical research, the weak role of professional associations in controlling the system and the inefficient health education were identified as important problems in the current health system (87.9%, 87.1% and 84.9%, respectively). The priority needs of health system improvement included adoption of social insurance for medical care of the poor (82%), enhancing the role of family medicine (77.2%), adopting health insurance system (76.1%) and periodic scientific evaluation of physicians and other health staff (69.8%).

CONCLUSION

Medical professionals were generally unsatisfied with the different aspects of the health system in Iraqi Kurdistan region. A number of problems and different priority needs for health system improvement have been recognized that require to be studied in more details.

Trends in childhood leukemia in Basrah, Iraq, 1993-2007

OBJECTIVES

Through a sister-university relationship between the University of Basrah and the University of Washington, we analyzed Ibn Ghazwan Hospital's leukemia registry data to evaluate trends in childhood leukemia since 1993.

METHODS

We documented leukemia cases among children aged 0 to 14 years for each of the last 15 years. Population data were obtained from a 1997 census and various subsequent estimates to calculate rates.

RESULTS

We observed 698 cases of childhood leukemia between 1993 and 2007, ranging between 15 cases (2.6 per 100 000 annual rate) in the first year and 56 cases (6.9 per 100 000 annual rate) in the final year, reaching a peak of 97 cases in 2006 (12.2 per 100 000 annual rate).

CONCLUSIONS

Childhood leukemia rates in Basrah more than doubled over a 15-year period. The test for trend was significant (P = .03). Basrah's childhood leukemia rate compared unfavorably with neighboring Kuwait and nearby Oman, as well as the United States, the European Union, and other countries.

Consanguinity and reproductive health among Arabs

Consanguineous marriages have been practiced since the early existence of modern humans. Until now consanguinity is widely practiced in several global communities with variable rates depending on religion, culture, and geography. Arab populations have a long tradition of consanguinity due to socio-cultural factors. Many Arab countries display some of the highest rates of consanguineous marriages in the world, and specifically first cousin marriages which may reach 25-30% of all marriages. In some countries like Qatar, Yemen, and UAE, consanguinity rates are increasing in the current generation. Research among Arabs and worldwide has indicated that consanguinity could have an effect on some reproductive health parameters such as postnatal mortality and rates of congenital malformations. The association of consanguinity with other reproductive health parameters, such as fertility and fetal wastage, is controversial. The main impact of consanguinity, however, is an increase in the rate of homozygotes for autosomal recessive genetic disorders. Worldwide, known dominant disorders are more numerous than known recessive disorders. However, data on genetic disorders in Arab populations as extracted from the Catalogue of Transmission Genetics in Arabs (CTGA) database indicate a relative abundance of recessive disorders in the region that is clearly associated with the practice of consanguinity.

Causes and differentials of childhood mortality in Iraq

BACKGROUND

Limited information is available in Iraq regarding the causes of under-five mortality. The vital registration system is deficient in its coverage, particularly from rural areas where access to health services is limited and most deaths occur at home, i.e. outside the health system, and hence the cause of death goes unreported. Knowledge of patterns and trends in causes of under-five mortality is essential for decision-makers in assessing programmatic needs, prioritizing interventions, and monitoring progress. The aim of this study was to identify causes of under-five children deaths using a simplified verbal autopsy questionnaire.The objective was to define the leading symptoms and cause of death among Iraqi children from all regions of Iraq during 1994-1999.

METHODS

To determine the cause structure of child deaths, a simplified verbal autopsy questionnaire was used in interviews conducted in the Iraqi Child & Maternal Mortality Survey (ICMMS) 1999 national sample. All the mothers/caregivers of the deceased children were asked open-ended questions about the symptoms within the two weeks preceding death; they could mention more than one symptom.

RESULTS

The leading cause of death among under-five children was found to be childhood illnesses in 81.2%, followed by sudden death in 8.9% and accidents in 3.3%. Among under-five children dying of illnesses, cough and difficulty in breathing were the main symptoms preceding death in 34.0%, followed by diarrhea in 24.4%. Among neonates the leading cause was cough/and or difficulty in breathing in 42.3%, followed by sudden death in 11.9%, congenital abnormalities in 10.3% and prematurity in 10.2%. Diarrhea was the leading cause of death among infants in 49.8%, followed by cough and/or difficulty in breathing in 26.6%. Among children 12-59 months diarrhea was the leading cause of death in 43.4%, followed by accidents, injuries, and poisoning in 19.3%, then cough/difficulty in breathing in 14.8%.

CONCLUSION

In Iraq Under-five child mortality is one of the highest in the Middle East region; deaths during the neonatal period accounted for more than half of under-five children deaths highlighting an urgent need to introduce health interventions to improve essential neonatal care. Priority needs to be given to the prevention, early and effective treatment of neonatal conditions, diarrheal diseases, acute respiratory infections, and accidents. This study points to the need for further standardized assessments of under-5 mortality in Iraq.

Diarrhoea and acute respiratory infections prevalence and risk factors among under-five children in Iraq in 2000

BACKGROUND

Diarrhoea and acute respiratory conditions are common medical conditions among under-five children in resource-limited and conflict situations. The present study was conducted to estimate the prevalence and associated factors for acute respiratory conditions and diarrhoea among children under the age of five years in Iraq in 2000.

METHODS

Data for the Iraqi Multiple Indicator Cluster Survey were obtained from UNICEF. We estimated the prevalence of acute respiratory conditions and diarrhoea. Assessment of the associations between these two medical conditions on one hand and socio-demographic and environmental variables on the other was done using logistic regression analysis. Weighted analysis was conducted to account for complex survey design.

RESULTS

A total of 14,676 children under the age of 5 years were reported by their mothers in the study. Of these 50.4% were males. About half (53.9%) of the children had complete vaccination status. Overall, 21.3% of the children had diarrhoea, and 6.9% had acute respiratory infection (ARI) in the last two weeks. In multivariate analysis, diarrhoea was associated with age of child, area of residence, maternal education, source of water, toilet facility, disposal of children' stool and disposal of dirty water. Compared to children aged 48-59 months, children in the age groups 6-11 months and 12-23 months were 2.22 (95%CI [2.02, 2.44]) and 1.84 (95%CI [1.71, 2.00]) times more likely, respectively, to have diarrhoea. Children whose mothers had no formal education were 11% (AOR = 1.11, 95%CI [1.04, 1.18]) more likely to have diarrhoea compared to children with mothers who had attained secondary level of education. Compared to children who belonged to households with unprotected well or river as the main source of water, children who belonged to households with piped water were 32% (AOR = 1.32, 95%CI [1.17, 1.48]) more likely to have diarrhoea while those who belonged to households with protected well were 26% (AOR = 0.74, 95%CI [0.62, 0.89]) less likely to have diarrhoea. Age of child, toilet facility, wealth, and sex of child were significantly associated with ARI.

CONCLUSION

In a study of under-five children in Iraq in 2000, we found that history of diarrhoea and ARI were negatively associated with lower socio-economic status, adequate disposal of children's stool and dirty water, but the results were inconsistent in terms of access to potable water and sanitation facilities possibly due to non-functioning of water and sewage plants after the war. Improvement in water quality and sanitation are vital in the reduction of diarrhoeal diseases.

Preconception health status of Iraqi women after trade embargo

OBJECTIVES

To describe the preconception health status of Iraqi women in 2001 following the trade embargo imposed on Iraq beginning in 1991 and only partially removed in 1996.

DESIGN

A descriptive cross-sectional prevalence study.

SAMPLE

500 Iraqi women at a premarital clinic in Baghdad in 2001.

MEASUREMENTS

Women were surveyed for age, area of residence, menstrual history, household crowding, consanguinity, and a family history of congenital problems. Clinical findings regarding height, weight, and hemoglobin level were included in the data.

RESULTS

Almost one third of the women were below the age of 20 and the majority were between 20 and 25 years of age. More than half of the women in this study had an intermediate-level education or less and lived in very crowded housing. Most of the women were anemic and reported a delay in menarche, suggesting malnutrition. Most of the women were planning consanguineous unions even though many reported congenital conditions in their family of origin.

CONCLUSIONS

Young Iraqi women who endured embargo needed, and continue to need, aggressive preventive health services to recoup health gains lost during the 1990s and to address prevention of common congenital disorders.

A response to criticism of our estimates of under-5 mortality in Iraq, 1980-98

According to estimates published in this journal, the number of deaths of children under 5 in Iraq in the period 1991-98 resulting from the Gulf War of 1991 and the subsequent imposition of sanctions by the United Nations was between 400,000 and 500,000. These estimates have since been held to be implausibly high by a working group set up by an Independent Inquiry Committee appointed by the United Nations Secretary-General. We believe the working group's own estimates are seriously flawed and cannot be regarded as a credible challenge to our own. To obtain their estimates, they reject as unreliable the evidence of the 1999 Iraq Child and Maternal Mortality Survey--despite clear evidence of its internal coherence and supporting evidence from another, independent survey. They prefer to rely on the 1987 and 1997 censuses and on data obtained in a format that had elsewhere been rejected as unreliable 30 years earlier.

Casualties: narrative and images of the war on Iraq

The Iraqi people have endured an excess burden of morbidity and mortality during the past 15 years due to war and sanctions, with the March 2003 Anglo-American assault on and subsequent occupation of Iraq representing the most recent chapter. Children have been disproportionately affected; many have died from infectious disease, malnutrition, and lack of access to health care. There have been significant differences in the availability of narrative accounts and images of this suffering, reflective of the need of those who wage wars and impose sanctions to keep the public uninformed. This article suggests that public health and medical practitioners have a responsibility to seek out such accounts and images. The authors explore possible responses to narrative and images of this suffering, and outline the sorts of responses engendered by three perspectives-charity, development, and social justice. The suffering of the people of Iraq should spur a response from the health community to alleviate the situation and prevent unnecessary suffering.

Mortality before and after the 2003 invasion of Iraq: cluster sample survey

BACKGROUND

In March, 2003, military forces, mainly from the USA and the UK, invaded Iraq. We did a survey to compare mortality during the period of 14.6 months before the invasion with the 17.8 months after it.

METHODS

A cluster sample survey was undertaken throughout Iraq during September, 2004. 33 clusters of 30 households each were interviewed about household composition, births, and deaths since January, 2002. In those households reporting deaths, the date, cause, and circumstances of violent deaths were recorded. We assessed the relative risk of death associated with the 2003 invasion and occupation by comparing mortality in the 17.8 months after the invasion with the 14.6-month period preceding it.

FINDINGS

The risk of death was estimated to be 2.5-fold (95% CI 1.6-4.2) higher after the invasion when compared with the preinvasion period. Two-thirds of all violent deaths were reported in one cluster in the city of Falluja. If we exclude the Falluja data, the risk of death is 1.5-fold (1.1-2.3) higher after the invasion. We estimate that 98000 more deaths than expected (8000-194000) happened after the invasion outside of Falluja and far more if the outlier Falluja cluster is included. The major causes of death before the invasion were myocardial infarction, cerebrovascular accidents, and other chronic disorders whereas after the invasion violence was the primary cause of death. Violent deaths were widespread, reported in 15 of 33 clusters, and were mainly attributed to coalition forces. Most individuals reportedly killed by coalition forces were women and children. The risk of death from violence in the period after the invasion was 58 times higher (95% CI 8.1-419) than in the period before the war.

INTERPRETATION

Making conservative assumptions, we think that about 100000 excess deaths, or more have happened since the 2003 invasion of Iraq. Violence accounted for most of the excess deaths and air strikes from coalition forces accounted for most violent deaths. We have shown that collection of public-health information is possible even during periods of extreme violence. Our results need further verification and should lead to changes to reduce non-combatant deaths from air strikes.

The role of the applied epidemiologist in armed conflict

BACKGROUND: Applied epidemiologists are increasingly working in areas of insecurity and active conflict to define the health risks, suggest feasible means to reduce these risks and, monitor the capacity and reconstruction of the public health system. In 2001, The Carter Center and the United States Institute for Peace sponsored a conference within which "Violence and Health" was discussed and a working group on applied epidemiology formed. The group was tasked to describe the skills that are essential to effective functioning in these settings and thereby provide guidance to the applied epidemiology training programs. METHODS: We conducted a literature review and consultation of a convenience sample of practitioners of applied epidemiology with experience in conflict areas. RESULTS AND CONCLUSIONS: The health programs designed to prevent and mitigate conflict are in their early stages of implementation and the evaluation measures for success are still being defined. The practice of epidemiology in conflict must occur within a larger humanitarian and political context to be effective. The skills required extend beyond the normal epidemiological training that focuses on the valid collection and interpretation of data and fall into two general categories: (1) Conducting a thorough assessment of the conflict setting in order to design more effective public health action in conflict settings, and (2) Communicating effectively to guide health program implementation, to advocate for needed policy changes and to facilitate interagency coordination. These are described and illustrated using examples from different countries.

'Iraq Water Treatment Vulnerabilities': a challenge to public health ethics

A formerly classified US document, 'Iraq Water Treatment Vulnerabilities,' provides evidence that ill health was knowingly induced in the population of Iraq through the ruination of that country's water purification system. We believe that the uncovering of this document should stimulate the public health community to clarify principles of public health ethics and to formulate statements giving voice to these principles. We propose here two statements, one dealing with the broad issue of public health ethics and international relations, and one dealing specifically with public health ethics and water purification.

Prophecies of childhood: how children's social environments and biological propensities affect the health of populations

During the past decade, important steps have been taken globally to improve the status of children. Concurrently, significant advances have been made toward understanding how child development is shaped by transactions between biological and environmental influences. Despite such advances, ongoing adversities in the lives of children worldwide undermine the development of individuals and thus the health of nations. The primary tenets of this paper are that: children continue to suffer a disproportionate share of the world's adversities; exposure to early adversities is not only associated with increased morbidity during childhood, but also across the lifespan; and recent advances in understanding the operation and ontogeny of stress-response systems can help explain how adversity is translated into lifelong effects on health. Acknowledging the long-lasting sequelae of childhood adversity has important implications for public health and society.

Life and death of children: the price of life

Nearly 2 million children die of simple diarrhea each year in developing countries. Those children would not have died if they were given Oral Rehydration Solution, which costs 100 yen for treating one child. In developed countries like Japan, treating one patient with intracranial aneurysm will cost over 2 million yen. The cost for treating one such patient could save 10,000 children with diarrhea even after adjusting with purchasing power parity in developing countries. Such inequity and inequality cannot be acceptable. We who are concerned about such a status quo have to work together for the betterment of children living in developing countries. In this review the author explores the root causes behind such unjust global structures.

Healthcare under sanctions in Iraq: an elective experience

As a consequence of the 1991 Gulf War and the ensuing UN sanctions, not only was the Iraqi government destroyed, but also the general infrastructure of the country was disrupted, with the civilian population and public services bearing much of the aftermath. Ten years after the war, the health system in Iraq is still in a perilous situation. The effects of sanctions have affected almost every aspect of medical care. There has been a mass exodus of health care professionals, many of whom were foreign nationals. Doctors' salaries fell rapidly to only $30 a month, barely enough to buy the necessities of daily living. Iraqi hospitals have no access to foreign journals, textbooks or the internet; leading to a generation of out-dated and under-skilled health professionals. Most worrying is the ever-present embargo on many essential medicines. Only one-third of the medicines are available for chemotherapy for the treatment of acute lymphoblastic leukaemia in children (UKALL 97 modified 99 protocol). At the Al-Mansour paediatric teaching hospital this shortfall has led to a substantial increase in childhood mortality, with disease-free survival rates falling to 25 per cent compared to 60 per cent in 1988.