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re : this week's Lancet

The current edition of The Lancet (27th May 2000, 355) carries two articles
on Iraq : 'Sanctions and Childhood Mortality in Iraq' by Mohammed Ali and
Iqbal Shah and "Baghdad 2000 - rubbish heaps and cesspits' by Peter Kandela,
as well as the following editorial. Both articles can be read in full on the
Lancet's website (, registration is free).

Both The Independent and The Guardian have reported on the articles /



This week's Lancet (p 1851 and 1893 ) carries two disturbing portraits of
the health situation in Iraq, almost a decade after the overt hostilities of
the Gulf conflict came to an end. Bringing the tools of epidemiology and
demography to bear on war-ravaged areas is always difficult, and Iraq,
despite its relatively well-developed infrastructure pre-war, has proved no
exception. Earlier studies have been criticised, but Mohamed Ali and Iqbal
Shah are very careful to reassure readers that their data from household
surveys a year ago in southern/central Iraq and in the autonomous northern
region are reliable. Peter Kandela tells us what it is really like in the
capital, Baghdad, in April, 2000: "In the terrible afternoon heat . . .
children were cooling themselves in a stinking cesspit . . . just a mile or
so from the presidential palace".

But which presidential palace? This innocent-sounding question sums up
persisting doubts about President Saddam Hussein's priorities for his
country. Despite the Oil-for-Food programme, his people are undernourished;
resources better allocated to rebuilding the country's infrastructure are
squandered on presidential pomp; and in the United Nations continuing
suspicion of Saddam's intentions means that contracts for anything that
might conceivably be weapons-related are put on hold. Last month more than
1000 applications to the UN Office of the Iraq Programme--most of them
relating to Iraq's requirements for electricity, water and sanitation,
transport, and communications, and valued at US$17 billion--were being held
up. One very significant problem now is spare parts for the oil industry.
There is no longer a UN-imposed ceiling on oil exports; the limiting factor
is the state of Iraq's oil- production capacity.

On food supplies, there is better news. UN agency reports from the mid-1990s
recorded serious undernutrition. The government of Iraq had for a long time
refused the plan for controlled exports of oil to be linked to equitably
distributed imports of food and medicines, with the UN acting as banker and
overseer; as a result, the first food arrived under the Oil-for-Food scheme
only in April/May, 1997. Before this, Iraq's own food-rationing plan was
yielding only about 1300 kcal daily; the UN's target "bread basket" provides
2150 kcal and next month this may be raised by a further 300 kcal. Whatever
doubts there may be about Iraqi government cooperation in other respects, UN
staff on the ground in Iraq believe that this sector of humanitarian aid is
working well with little evidence of these supplies being diverted to the
wrong hands. Nonetheless it would be no bad thing for the World Food
Programme to repeat the surveys conducted 3 years ago. Such surveys might
reveal neglected subpopulations or defects in the nutritional balance, such
as too little protein and fresh fruit and vegetables.

A wide range of factors conspires to bring about the current medical
situation in Iraq. We cannot single out food shortages, reduced incomes,
poor electricity and water supplies, shortages of drugs and medical
equipment, the intellectual isolation, or the emigration of Iraqi
professionals. The latest evidence shows that in the northern autonomous
region child mortality is now improving while in the rest of Iraq it is
getting worse. In a way this is a natural experiment but not one from which
a practical conclusion can be drawn. Respect for the sovereignty of Iraq is
central to UN policy, and the relatively privileged way in which aid is
handled in the north cannot simply be extended to the south.

The UN Secretary-General recognises that in terms of the United Nations
objective to relieve suffering, the Iraq dilemma is almost unresolvable. " .
. . here we are", he says "accused of causing suffering to an entire
population". The UN risks "losing the argument, or the propaganda war--if we
haven't already lost it--about who is responsible for this
situation--President Saddam Hussein or the United Nations". Yet even Kofi
Annan finds the only solution to be that Iraq complies in full with what the
UN Security Council has demanded. The primary responsibility for this
disaster is Saddam's. The UN, an increasingly divided UN we should add, has
become a secondary perpetuator of it. The courageous policy--one by chance
hinted at in the first of last week's Lancet essay series on violence--is to
suspend (not abandon) sanctions lest upcoming generations of Iraqis, out of
resentment, suffering, and isolation, grow up to be as aggressive as their
current leader.

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