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[casi] The Lancet: special report

[ Presenting plain-text part of multi-format email ]

The Lancet: Volume 361, Number 9358 22 February 2003

Special report

      The people of Iraq face a grim future with or without a war

A United Nations taskforce has estimated that if war breaks out in Iraq at least 74 million people 
will need immediate humanitarian aid but this immense caseload would only represent the people that 
aid workers could reach. Access to needy civilians in other governorates will either be denied or 
be impracticable, according a recently leaked UN report written in December, last year.

Unlike the 1991 Gulf war, "this confrontation is expected to develop beyond the preparatory, and 
relatively short, aerial bombardment of infrastructure, towns, and cities into a potentially large 
scale and protracted ground offensive, supported by aerial and conventional bombardment", said the 
UN report.

The consensus among the aid community is that the Iraqi population, already severely weakened by 
the Gulf war, 12 years of sanctions, and almost sole reliance upon Hussein's government, will need 
a long-term, comprehensive aid strategy.

According to a report published by the UK's Oxford Research Group (ORG) in October last year, the 
allies strategy will be to quickly destroy Iraq's military and administrative infrastructure, 
access to electricity supplies, and any civil activities that could support Iraq's defences. And 
then draw out Hussein's elite forces, which will be mainly concentrated in and around Baghdad, and 
to attack them with intense aerial bombardment and ground forces.

Other key elements of the campaign will be to secure the major oil producing regions, such as Basra 
in the south. Troops will also try to gain control of the Kurdish region of northern Iraq, for 
which preparations have already begun with the repair of three major airfields in the area. Forces 
will also attack from Jordan, moving swiftly though the deserts in western Iraq towards major 
cities, such as Baghdad.

The most intense fighting will probably be around Baghdad, considering the allies declared ambition 
for "regime change". But the allies' experience from the 1991 Gulf war suggests that the Iraqi 
government may use chemical and biological weapons if its survival is threatened. Furthermore it 
may launch strategic strikes on neighbouring countries, said the author of the ORG report, Paul 
Rogers, professor of peace studies at University of Bradford, UK. In such circumstances the UK 
government would be prepared to use a nuclear weapon on Baghdad if allied and civilian casualty 
rates escalate, warned Rogers.

The destruction of command and control systems of the Iraqi military, including dual-use electrical 
circuits and grids "could destroy power supplies in most parts of the country" said US-based 
Physicians for Human Rights (PHR), in a statement published in December, 2002. "A public-health 
emergency created by an impaired infrastructure exacerbates the Iraqi population's vulnerability to 
disease and hunger, given the already degraded condition of health facilities, potable water, and 
limited food supply", said PHR.

The results of a needs assessment presented in the UN report supports this grim view. 60% of Iraq's 
population--about 16 million people--are wholly dependent on government distributed food from the 
UN's oil-for-food programme. During a war, existing supply lines will be either shut down or 
rerouted. For example, the three northern governorates, home to 37 million people, will need 
access to an alternative supply line of food because established routes from Mosul and Kirkuk in 
the south will be inaccessible.

Iraq has tried to grow its own food but has been crippled by a major drought in the past 3 years, 
noted Oxfam in a briefing paper published in December, last year. Attempts to irrigate the land 
have been hampered by the sanctions. The 2002 wheat harvest of 16 million tonnes will run out in 
early 2003, added Oxfam.

Currently food is distributed 21 days per month by the government and non-governmental 
organisations (NGOs) to about 1 million people per day. This "begs the question of how the 
population's basic needs will be met when government operations and transport and storage 
infrastructure are disrupted or destroyed by war", said Joel Charny, vice president of policy for 
Refugees International in a statement published on Feb 5.

The UN agrees and said that during a war people will not be able to get to distribution centres. If 
war breaks out the distribution system will grind to a halt. But if military intervention begins 
simultaneously from the north and south, the peripheral governorates of Basrah, Maysan, Thi Qar, 
Muthana, Najaf, Kerbala, and Qadisiyah will be immediately affected, said the report. "Most 
household food reserves will not last 2 months if distribution were interrupted or suspended."

Today, Iraq's health sector has a 4-month supply of basic medicines and medical supplies. But these 
stocks will be inadequate during and after a war. Immediate health concerns during a war will be 
conflict-related injuries. But as war progresses there will be a rapid increase in diarrhoeal 
disease if access to potable water is denied, and if oil wells are sabotaged the contaminated air 
will cause a simultaneous rise in respiratory infections.

      Immediate humanitarian needs if war breaks out

     Bridging, material handling, and transport

     Food and necessities for 54 million people

     Health supplies for 100 000 injured people

     Health supplies for 123 million highly vulnerable people

     Health supplies for ongoing needs of 54 million people

     Nutrition supplies for 054 million people

     Water treatment equipment for 54 million people

     Chemicals and consumables for 54 million people

     Sanitation materials and chemicals


NGOs and allied aid suppliers will have to gear up for "diseases in epidemic if not pandemic 
proportions", said the UN report. Cholera and dysentery will thrive, as will measles, meningitis 
and other preventable diseases--due to low vaccination rates.

The UN's estimates for southern and central parts of Iraq suggest that, excluding elderly people 
and patients with chronic diseases, aid workers will be faced with a caseload of 52 million 
vulnerable people. This will include 42 million children younger than 5 years old, 1 million 
pregnant and lactating women, and 2 million internally displaced people. However, if a war begins 
UN teams will only have immediate access to 123 million people in the south.

The nutritional status of about 3 million Iraqis will be in a "dire" situation and will require 
sustained, therapeutic feeding. Among the most vulnerable in this population will be patients in 
hospital, which have an overall capacity of 27 000 beds, 5000 patients confined to institutions, 
"comprising orphaned children the severely handicapped, and children in detention, and 21 000 

The infrastructure of Baghdad and the central region of Iraq will be systematically destroyed by 
allied bombardment and may be sabotaged by retreating government forces. The allies will focus on 
anything to do with oil and electricity production. The report notes that the "availability of 
potable water will be curtailed extensively . . . and in the worst case fuel will have to be 

The loss of electricity and fuel supplies will have a major impact at the household level but 
should not affect immediate relief efforts. However, just for the northern governorates aid workers 
will have the immense task of bringing in fuel supplies including 30 million litres of gasoline, 40 
million L of kerosene, 30 million L of diesel, and 10 000 tonnes of cooking gas. To complicate 
matters, there is little storage capacity in this region and available refining capacity will be 

The destruction of electricity supplies will in turn disable water and sewage treatment centres. 
Currently piped water reaches 457% homes but 65% of the water isn't treated. The fleet of water 
tankers on which half the urban population depends is also falling apart as the supply of spare 
tyres and parts dwindle.

      Casualties and deaths for all sides if war breaks out


     Iraqi combatant deaths
     12 000-50 000

     Iraqi civilian deaths
     12 000-50 000

     Coalition combatants deaths

      Basra, Diyala, Kirkuk, Mosul

     Iraqi combatant deaths
     1200-30 000

     Iraqi civilian deaths
     1200-30 000

     Coalition combatants deaths

      Within 3 months of end of conventional war

     Iraqi civilians
     44 000-6 000

     Iraqi civilian deaths in civil war
     420 000

     Refugee deaths
     415 000-30 000

     Children under 5 excess deaths
     523 500

      Nuclear attack on Baghdad only

     306 600-3 608 000

     Total possible deaths on all sides during

     the conflict and the next 3 months,

     excluding civil war and nuclear attacks
     48 716-261 100

      Source: Collateral Damage by MedAct

Water treatment plants that have emergency electricity generators cover 70% of the urban population 
but only 10% of rural people. UNICEF has warned that at least 39% of people will need to be 
supplied with water rations but the immediate need will be to supply 407 million people.

The country's sanitation system is also in a sorry state of repair with 500 000 tonnes of raw 
sewage pumped daily into fresh water sources. Half of all sewage treatment plants do not work and 
of those that do 25% do not meet Iraq's environmental standards, said Oxfam in a paper published in 
December, 2002. The UN has noted that of the 5 million people living in Baghdad, 4 million have 
access to a sewerage system. If electricity supplies are disrupted NGOs are concerned that that 
only 10% of the sewage treatment plants serving Baghdad have emergency electricity supplies.

"It cannot be emphasised to strongly that even a 'best-case' scenario of a limited war of short 
duration, perhaps comparable to 1991, would have much greater impact on the Iraqi people", said 
MedAct, the UK affiliate of International Physicians for the Prevention of Nuclear War, in a report 
published last year.

Aside from impact on Iraqis, MedAct noted that the Gulf war had a dramatic effect on neighbouring 
countries--the clean up costs for Iran, Turkey, Jordan, and Saudi Arabia were $150-200 billion. 
Trade reduction and soaring oil prices also had "devastating consequences in developing countries" 
and reduced growth in 40 of them by 1% of gross national product--reaching the UN threshold for 
disaster relief.

MedAct warns that "if the war is likely to cause worse problems than those it sets out to solve, 
then it is ill-advised under any circumstances, and other options must be explored".

Haroon Ashraf

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