The dissolution of Iraq’s once-prestigious healthcare system represents the tragic culmination to a longer trajectory of decline marked by war, sanctions, funding shortfalls, and neglect over three decades.

In April 2016, dozens of medical doctors in the pilgrimage city of Najaf protested the Iraqi government’s failure to provide security at the country’s hospitals. Although their gathering was tiny by Iraqi standards, the demonstrators sought to highlight the troubling trend toward violence at Iraq’s clinics and emergency rooms. The general breakdown of public order precipitated by ISIS’s dramatic advances in summer 2014 has exposed medical practitioners to retribution from grieving families, powerful tribes, and militia commanders. In a country where anger, frustration, and sorrow have few outlets, Iraqi doctors are on the frontline of a different kind of war as violence seeps from the battlefield into the hospital wards where victims seek refuge.

The instability across Iraq’s once-prestigious healthcare network represents the tragic culmination to a longer trajectory of decline marked by war, sanctions, funding shortfalls, and neglect over nearly three decades. Before the imposition of international sanctions in 1991, Baghdad operated some of the most professional and technologically advanced healthcare and public health institutions in the Arab World. Efforts to resuscitate medical infrastructure since 2003 has been hindered by insecurity, a chronic lack of utilities (including clean water and electricity), and a steady exodus of well-trained doctors to neighboring Arab countries, Europe, and North America. In the last two months of 2015 alone, over 330 specialists fled the country. And with the fight to clear ISIS from Mosul grinding on since October 2016, the country’s already struggling public healthcare services are overwhelmed by rising military and civilian casualties.

The story of Iraq’s healthcare system over the past 40 years is more than a simple narrative of dissolution or unchecked chaos. It illustrates the upheaval to which the country’s society has been subjected over a relatively short period, and the deeper transformations such forces wrought on the state’s political, demographic, and economic character. Without bolstering means of delivering treatment to its people, the Iraqi government will struggle to manage physical and psycho-social traumas left on communities across the country after years of omnipresent violence.

Treating the Modern Nation-State

Healthcare professionals have played critical roles shaping Iraq’s political development since the establishment of systematized public health infrastructure in the early twentieth century. Institutions like Baghdad’s Royal College of Medicine, which opened its doors in 1920, helped foster the slow evolution of a sophisticated and centralized healthcare delivery system staffed by local doctors. As Omar Dewachi, an Iraqi anthropologist at the American University of Beirut, concludes: “the subsequent expansion of public health and healthcare to rural areas in Iraq, and the creation of strong post-graduate opportunities…through training of specialists and experts abroad were crucial in the process of the formation of the nation-state.” In the 1970s and 1980s, the Iraqi government directed a significant portion of its growing oil revenue to support public healthcare delivery and institutions — a policy that would, in turn,  precipitate decay in the 1990s after the country’s oil sales were blocked. As medical staff and the institutions where they worked developed, so too did the communication and supply networks supporting them. With the expansion of Iraqi infrastructure, healthcare facilities were linked by reliable and efficient modes of road and rail transportation, allowing for experts and patients to move between regions with relative ease. By the 1970s, the country boasted a well-functioning water and sanitation system, which could deliver safe drinking water to approximately 90 percent of the population.

The story of Iraq’s healthcare system over the past 40 years is more than a simple narrative of dissolution or unchecked chaos.

Infrastructure development led to improved healthcare outcomes during the mid-twentieth century. While government public health data is relatively sparse for the pre-1991 period, the World Health Organization (WHO) noted a significant reduction in childhood mortality between 1960 and 1990. During that period, the infant death rate dropped from 71 deaths per 1,000 live births (1965) to 29 (1989); under-five mortality declined from 111 to 44 deaths per 1,000 live births; and average life expectancy rose from 58.2 years to 66.2 years. By the late 1980s, Baghdad’s centralized public healthcare network reached nearly 97 percent of the urban population and 79 percent of rural communities, facilitating the exchange of ideas – medical, as well as social, cultural, and political – between hinterland, regional city-centers, and the capital. Critical health indicators, and the infrastructure behind the figures, steadily improved even as Iraq experienced political turmoil in the latter half of the twentieth century, including the fall of its monarchy in 1958, a number of coups d’état, and the devastating Iran-Iraq War (1980-1988).

By 1989, Iraq’s healthcare system functioned under the direction of a cadre of well-trained physicians and specialists. That year, records show the Ministry of Health operating 172 modern state hospitals, 1,200 primary healthcare centers, and 850 community health centers with an annual budget of $450 million. Although vicious, the Iran-Iraq War was fought mainly by ground forces, leaving healthcare infrastructure intact. The need to manage the massive waves of battlefield casualties sparked the development of efficient emergency and trauma wards at major urban hospitals, including surgical units that could perform complex reconstruction operations. While generally remarkable, some of this progress was a product of increasingly coercive policies – including travel bans – adopted by the Saddam Hussein regime to keep doctors from practicing abroad.

The development of healthcare institutions and practitioners highlights the general trajectory of Iraqi economic and social indicators before the 1980s: spectacular growth followed by equally dramatic collapse during the 1991 Gulf War and its aftermath. Deliberate targeting of civil infrastructure by US airstrikes during the 1990-1991 Gulf War and enduring UN sanctions — imposed only days after the Iraqi invasion of Kuwait — dissolved the foundations on which Iraq’s medical infrastructure was built. Yet, the growth of healthcare capacity during the mid-twentieth century offers important historical precedent for those seeking to reconstruct capacity today in a country with legacies of professionalism and expertise.

Dissolution during the Sanctions Decade, 1990-2003

Saddam Hussein’s miscalculation in Kuwait had tragic implications for Iraq – still exhausted by the eight-year war with Iran. In January 1991, American and allied air forces launched Operation Desert Storm, consisting of a 42-day air war followed by coalition ground operations into Kuwait. These forces quickly routed Saddam’s military and moved through the sand berms into the southern Iraqi desert. Between 16 January and 27 February nearly 88,000 tons of munitions were dropped on Iraq — an explosive payload equivalent to seven Hiroshima-size atomic bombs. The Iraqi Red Crescent estimated that the Coalition bombardment killed between 3,000-4,000 civilians (and as many as 35,000 soldiers).

Four months before kinetic operations against Saddam began, the UN Security Council had passed Resolution 661 — the first of its many sanctions agreements during the 1990s — restricting all imports from Iraq and occupied Kuwait; oil sales, which formed Iraq’s economic foundation, ceased. Although the policy excluded humanitarian materiel from the ban, its effective blockage of Iraqi government revenue sources translated into diminished capacity at the country’s healthcare system. Commodities essential for civilian survival were soon in short supply, including certain medicines, water purifiers, hospital equipment, and infant milk formula. These measures complemented physical destruction, further crippling Iraq’s healthcare institutions and ability to deliver treatment. Between August 1990 and January 1991 these measures cost Saddam’s government nearly $18 billion, with a yearly loss projected at over $22 billion in lost oil sales. As early as 7 February 1991, the Iraqi Red Crescent estimated that the blockade had caused 3,000 infant deaths due to lack of formula. Water and sanitation systems quickly collapsed; food was already in short supply; and hospital provisions (medicine, disinfectants, anesthetics, and equipment) were depleted without prospect for replenishment. Airstrikes had targeted sewage treatment facilities, and by March the Tigris River was “running thickly and slowly with human waste,” according to a Baghdad University Law Professor. An 87-member international monitoring committee reported that in Iraq’s 30 largest cities, electricity, water, and sewage services were close to total collapse.

The “sanctions decade” witnessed a drastic reduction in health indicators across Iraq. In the eight-month period following the Gulf War in 1991, under-five mortality rose from 52 to 128.8 deaths per 1,000 live births; the death rate in rural areas rose a further 30 percent. According to WHO data from 1994, the excess mortality rate for children rose to a further 3.6 deaths per 1,000 live births, due mainly to diarrhea and acute respiratory infections. By 1996, 20 percent of children were underweight. A UN report thus concluded that “the children of Iraq up to the ages of puberty are the most traumatized children of war ever described.” Maternal mortality figures during the mid-to-late 1990s painted an even clearer image of dissolution at Iraq’s hospitals and clinics: in 1999 the number of women who died during or immediately after childbirth had more than doubled from the pre-sanctions figure, highlighting lack of access to care or inadequate treatment.

As Iraqi coffers emptied under sanctions, the regime cut funding for the Ministry of Health by 90-91 percent. Doctors’ salaries dropped accordingly – a striking decline for a group traditionally considered among the country’s most elite social classes. National poverty rates rose from 41 to 70 percent; after the dinar’s value collapsed, a physician’s salary fell from around $3,000/month in 1989 to as low as $2/month. Facing an untenable financial situation, many professionals left Iraq for other Arab countries (mainly Lebanon, Jordan, Syria, Yemen, and Libya), Europe, and the U.S. As talent moved abroad, Iraq’s domestic healthcare system grew increasingly politicized and poorly suited to respond to changing health needs. One doctor from Mosul recalled the sanctions-decade thus: “To deny a nation access to antiseptics, antibiotics, and other medical supplies, thus rendering disease untreatable — that is…a form of biological warfare. To deny people electricity for hospitals, sufficient food, or clean water — that is a gross violation of humanity.” The UN presented a starker conclusion, declaring that by 2003 “Iraq’s health outcomes were among the worst in the region…[and] resembled some of the world’s least-developed countries.”

Finding Treatment under Occupation, 2003-2014

Iraqi healthcare’s dissolution through the 1990s set the stage for sustained tragedy in the twenty-first century. In the five years following Saddam’s ouster, an estimated 18,000 doctors, representing over half of those who remained in the country, left Iraq. A 2012 Johns Hopkins University survey conducted with 401 Iraqi doctors in Jordan indicated that, nearly a decade after the U.S.-led invasion, physician emigration had increased over pre-2005 levels; by the time American soldiers withdrew from the country in December 2011, doctors in Baghdad were being killed at a rate of 47.6 per 1000 professionals; that year, nearly 5,400 doctors were emigrating annually. 

For those who remained, their ability to practice diminished throughout the mid-2000s. A report published by the Lancet in 2004 noted that many doctors felt compelled to carry firearms into their workplaces, fearing looters and random attacks. These concerns were not unfounded: shortly after the US-led invasion in 2003, Muhammad al-Rawi – who had been acting as interim President of Baghdad University – was assassinated by unknown gunmen in his medical clinic. As sectarian groups and militias gained power after 2003, hundreds of physicians became victims of targeted killings and kidnappings.

The medical “brain drain” impacted health outcomes across Iraq after 2003. According to the WHO’s 2008 Family Health Survey Report, violence-related mortality constituted up to one in eight deaths across the country. Women and children were particularly vulnerable to deteriorating healthcare infrastructure and delivery mechanisms: many mothers could not reach hospitals for routine maternity care or delivery; infants and children could not receive essential immunizations as medical supply delivery was hindered by corruption at the Ministry of Health; and electricity shortages impacted doctors’ ability to make proper diagnoses. A joint UNICEF/Iraqi government survey concluded in 2011 that the number of fully immunized children had dropped from 60.7 percent in 2000 to 46.5 percent by 2011. The University Collaborative Iraq Mortality Study — the best survey covering the post-2003 period — indicated a rise in the general mortality rate, with the rate for males climbing from 3.7 to 7.9 deaths per 1,000 between 2003 and 2011. Between 2003 and 2011, the survey ultimately found approximately 461,000 excess deaths due to wartime conditions

By January 2012, Iraq had an estimated 7.8 physicians per 10,000 people – a rate three times lower than in neighboring countries like Jordan, Lebanon, Syria, and the Palestinian Territories. Subsequent World Bank data indicates a decline in average life expectancy, from 69.2 years in 2000 to 68.5 in 2010 – with significantly lower figures from rural areas that have largely been excluded from the post-2003 state reconstruction effort. International efforts to rehabilitate war-damaged healthcare infrastructure, along with restructuring of Iraqi government funding priorities, increased the number of public primary and emergency healthcare facilities. In 2003-2009, the US government allocated $13.4 billion to rebuild Iraq’s healthcare services, through the Iraq Relief and Recovery Fund. These and other international efforts had, by 2012, produced limited improvements. For example, that year Iraq had an average of 7.4 primary healthcare facilities per 100,000 people — up from 5.5 a decade earlier. Yet, these facilities remained understaffed and poorly resourced, as the pace of facility improvement could not keep up with population growth and displacement. Today, Iraqis with financial means instead seek treatment at private hospitals in Beirut, Amman, Istanbul, Tehran, Delhi, or in the Kurdistan region – fueling a “therapeutic travel” industry in places like Lebanon, where illuminatingly-named “Weekend Hospitals” have emerged.

During Iraq’s 2006-2008 sectarian civil war, insecurity compounded the infrastructure and expertise deficit at hospitals across the country. As part of a quota-based power-sharing arrangement in 2006-2007, the Ministry of Health came under the control of Shia cleric Moqtada al-Sadr’s political allies and their Mahdi Army. Shia militias abducted and murdered sick or wounded Sunni patients, allegedly with support from high-ranking Ministry of Health officials. Such accusations were supported by the 2007 arrest of deputy health minister Hakim al-Zalimi, who was implicated for co-opting the ministry as an operational body for the Mahdi Army. Within this context, Iraq’s healthcare network not only failed to deliver adequate care to vulnerable populations, but also evolved into a tool with which various groups could manipulate sectarian grievance across communal and sectarian lines. As Omar Dewachi explained, “hospitals in…Baghdad were thus transformed into ‘killing fields.’”

Following the civil war, the Iraqi government invested in a network of private domestic and foreign hospitals to provide healthcare for its citizens, recognizing the structural obstacles preventing adequate reform in the public healthcare sector. In Baghdad, individual physicians or entrepreneurs provide surgical beds, operative and labor theatres, medical labs and X-ray units – sometimes in support of public hospitals. Yet, for more general or expert care, Iraqis often seek treatment abroad – an outflow partially encouraged by official funding programs. The Rafik Hariri Hospital in Beirut, for example, received funding from the Iraqi government to construct a series of wards specially designated for Iraqis, and compensates citizens for travel expenses after an extensive triage process. Subject to what is often a lengthy case-by-case deliberation, many of these patients arrive in Lebanon during the final stages of their illness, when treatment is least effective. Numerous small businesses that transport corpses from Beirut to Iraq, which had existed in Lebanon for decades, boosted their operations and prices — charging a middleman fee of between $2,500 and $3,500, depending on body weight.

Managing the ISIS Nightmare

The commercialization of Iraqi life and death abroad is symptomatic of broader institutional decay in Baghdad since the 1980s, which precludes sustainable development of the country’s healthcare sector. As Iraq’s policymakers look to address physical, as well a psycho-social trauma inflicted after ISIS’s dramatic 2014 offensive, such long-term consideration will be crucial.

Today’s security and humanitarian emergencies have exacerbated the challenges faced by already-crippled medical institutions to meet rising need. As casualties mount during ongoing fighting against ISIS, hospitals struggle to manage an overwhelming influx in patients – many of whom suffer from combat-related traumas. Since the launch of operations to liberate Mosul on 17 October until late February 2017, approximately 1,675 civilians have been referred for treatment in the Iraqi Kurdish capital of Erbil – although these civilians must navigate an unpredictable transit. As Johns Hopkins University researcher Mac Skelton found, documents issued on the Mosul side are not necessarily valid in Iraqi Kurdistan: “Ultimately, it is up to the [Kurdish] officer manning the checkpoint to decide whether a patient represents a security threat or not.” Remaining civilians in Mosul often seek trauma and emergency care at Iraqi Special Operations Forces (ISOF) field hospitals, which the US and other counter-ISIS coalition nations have funded, as well as at primary healthcare clinics established by Iraqi and international organizations. The Iraq Health Action Organization (IHAO), for example, operates a growing number of frontline healthcare facilities in Mosul, providing maternal, neonatal, and early childhood care for civilians in recently-liberated zones.

The development of healthcare institutions and practitioners highlights the general trajectory of Iraqi economic and social indicators before the 1980s: spectacular growth followed by equally dramatic collapse during the 1991 Gulf War and its aftermath.

Mosul’s university – once regarded as among the finest in the Middle East – has been severely damaged by coalition airstrikes and ISIS activity since 2014. Other public institutions have fared little better; unofficial reports indicate that, as the Iraqi Army advances through Mosul, ISIS has forcibly transferred the city’s remaining physicians to ISIS-held territory in Deir Ez-Zour, Syria. The manager at Muharabeen Hospital in eastern Mosul thus lamented, “on average, we are receiving 850 outpatients every day, 50 emergency cases, and between 20 and 30 new trauma injuries, mostly from mortars. We urgently need support and will accept help from anyone.” For those suffering from non-traumatic illnesses – including various forms of cancer, which are prevalent in Iraq – access to desperately-needed treatment has diminished or completely disappeared.

The process of reconciling aggrieved communities after ISIS will hinge on Iraq’s ability to care for civilians’ immediate needs while implementing reconstruction and support programs over the long-term to address deeper psycho-social impacts. Traditionally, the Iraqi healthcare system – like many across the Arab World – has not devoted significant resources to treating psychological trauma issues or treatment. Yet, after nearly 40 years of cyclical conflict, culminating in the heightened violence over the past two and a half years, successive generations carry their wartime experiences, exhibited as symptoms of Post-Traumatic Stress Disorder. Iraq’s medical institutions lack trained caregivers or facilities to manage this enduring crisis, leaving non-government and civil society organizations to deliver much-needed psycho-social counseling when and where they can. For example, groups like the SEED Foundation in Iraqi Kurdistan have launched psychology trainings at regional universities, and provide mental health clinicians to displacement camps. In Dohuk, an ongoing project funded by the German state of Baden Wuerttemberg will establish a psychological trauma institute at the city’s university to train mental healthcare practitioners. As Iraqi healthcare institutions struggle to build similar capacity, such non-governmental efforts will remain critical.

The deterioration of Iraq’s healthcare system ultimately leaves communities impacted by violence without the support or treatment needed to recover. Massive brain drain across the medical profession since the 1980s, compounded by infrastructure damage and targeted political violence, has left Iraq without the physicians needed to care for traumatized populations. Yet, the country’s pre-1991 public healthcare legacy offers some clues for policymakers trying to deliver medical services through a national network. Further investment by the Iraqi government, its international partners – and reinforced by programming from other non-government organizations and multinational bodies – is necessary to spark this broader reconstruction process. Without such sustained investment in Iraq’s struggling public health system post-ISIS, Baghdad risks a deeper crisis among its most vulnerable populations.