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[casi] Three risks: Drugs, food, and security

The worst-case humanitarian scenarios for the latest Iraq war were avoided for a
variety of reasons:
>> Large scale urban conflict (the 'seige of Baghdad') didn't occur
>> Civilian infrastructure was largely spared
>> Civilian coping strategies were more resilient than expected
>> Refugee populations were smaller than feared

As a result -- while there were isolated cases of cholera (for example) in
southern Iraq -- there appear to have been no large scale outbreaks as had been

However, none of the above risks have been alleviated.
>> Low-intensity urban conflict continues, and security concerns disrupt
food/medical deliveries and threaten foreign workers
>> Civilian infrastructure remains extremely fragile ... a legacy of sanctions,
war, and looting
>> Iraqis continue to face day-to-day challenges, expecially those facing
medical or other emergencies
>> Existing refugee populations have been slow to re-integrate.

Below are three articles covering the current status of Iraq's medical system,
food rationing (and the transition from OFF), and security concerns for aid

Drew Hamre
Golden Valley, MN USA


Drugs crisis threatens to break fragile health service

Although sanctions are over, Iraq's hospitals must rely on old stock and looted

Rory McCarthy in Baghdad
Wednesday October 15, 2003
The Guardian

Hadir Diya is back in a grimy bed at Baghdad's al-Kadhimiya teaching hospital
for another bout of treatment for leukaemia. Her mother sits by her side and
smiles, grateful that after three years, her daughter's disease is in remission.
Dr Wasim al-Tamimi is much more worried. He has seen cases like this too many
times before. Hadir, 18, is having chemotherapy but for years the doctors have
had no supplies of a drug she vitally needs - Mercaptopurine - which is commonly
used across the world to suppress the symptoms of this acute lymphoblastic

Without it, the leukaemia is likely to reappear and will probably one day claim
Hadir's life.

"She has been on an incomplete drug regime ever since she was first diagnosed,"
he said.

"Without this drug there is a real danger of relapse. We have seen it happen
before. But this drug is just not available."

Hadir's mother, Iman, spent 150,000 Iraqi dinars (£55) on 25 tablets of the drug
that will last her daughter little more than a week.

"It is very expensive and it's getting harder and harder to find," she said.

Under the UN sanctions imposed on Iraq throughout the 1990s, the delivery of
many of these life-saving drugs were delayed or refused entry into Iraq.

Six months after the fall of Saddam Hussein's regime, the drug shortage is as
serious as ever. It has fast become the biggest crisis facing Iraq's fragile
health service and a severe test of America's bold promises for post-war Iraq.

Last week Dr al-Tamimi watched another of his leukaemia patients die. The woman,
aged 32, had suffered from acute myeloid leukaemia for three years. Dr al-Tamimi
wanted to treat her with another drug commonly used in the west called Atra, or
All-trans-retinoic-acid, which forces leukaemia cells to rapidly mature and die,
forcing the disease into remission.

This drug has not been available in Iraq for years and even now cannot be bought
in pharmacies.

Twice in the past the woman's parents travelled across the border into Jordan to
buy a supply of Atra. Twice she went into remission. Two months ago she was
brought into the al-Kadhimiya again to be treated for a third relapse. Again her
parents travelled to Jordan to buy the drug, but when they returned last week
they were too late.

"On the day the drug arrived we lost her," said Dr al-Tamimi.

"She died simply because the drug is not available in Iraq. We come across these
cases all the time."

Only wealthier families can even think of travelling to Jordan to shop for
life-saving drugs such as Atra.

A three-month course costs a crippling 42m Iraqi dinars (£15,000). "Sometimes
the families ask if there is a drug abroad that can help," the doctor said.

"If they are poor we don't even tell them. We don't want them to feel they have
failed to do something to help their relative. This has become something we are
used to."

While the US has spent millions of dollars repairing Iraq's oil fields, hunting
for weapons of mass destruction and catering for the 150,000 troops deployed in
Iraq, the country's ailing health service is struggling to stay afloat.

Aid workers say the Coalition Provisional Authority (CPA) in Baghdad, has failed
to realise the scale of the crisis and many fear the entire health sector is
simply being lined up for privatisation.

"It is completely unclear what is going on," said Thomas Dehermann, the head of
mission for Médecins Sans Frontières in Baghdad. "Because they are not coping
they don't want us to know."

For now, hospitals are reliant on old stocks, many of them looted after the war,
and on vital drug shipments from the World Health Organisation. WHO is
delivering $130m worth of medicines paid for by Saddam's government under the
oil for food programme along with an extra $18m worth bought by WHO itself.
Every other day 15 truckloads of medicines are brought into Baghdad but the
deliveries will cease in late November when the oil for food programme ends.

Saddam's reign left Iraq the legacy of a highly centralised, bureaucratic and
frequently corrupt health system. A state firm, Kimadia, is responsible for
buying in all medicines for government hospitals and all private pharmacies. But
the Guardian has learned that in the six months since the war, Kimadia has only
secured two drug deliveries, neither of which are for much-needed lifesaving
drugs. One delivery was for 50,000 rabies vaccines and the second was for 2m
chlorine tablets, for water purification.

Taha Omran, Kimadia's deputy director, blames the drug shortage on bureaucracy
and a lack of funding from the CPA.

"Here in Iraq we don't have the communications we need to buy the best quality
drugs from abroad and the ministry of health only restarted three or four weeks
ago," he said.

The CPA has given the ministry a $210m budget until the end of this year, of
which $125m can be spent on importing drugs and medical equipment.

"It is just not enough to face our urgent needs," Dr Omran said.

Under Saddam, Kimadia relied on heavy subsidies to buy its drugs. Now it must
pay the much higher market price. The CPA has also told him that in the coming
months the supply of drugs in Iraq will be part privatised.

Even the most basic work at Kimadia, including an inventory of existing drug
stocks, has yet to happen, said Mr Dehermann.

He said: "They need to do an inventory and they need to find out how they are
going to support Kimadia once the oil for food pipeline stops."

US officials working on Iraq's health sector say today's problems are a result
of three decades of mismanagement and corruption under Saddam Hussein.

James Haveman, the senior American adviser at the health ministry, said limited
budgets were also to blame and that until next year Iraq would have to rely on
the WHO drugs now being delivered.

"I only have enough money in my budget to buy ahead for next year," he said.

"And we know there is not enough money in the budget to meet the equipment
needs. Does it pain me when I go through these hospitals? It surely does. Can we
do something better for them? Yes, we can."

· A car bomb exploded yesterday near the Turkish embassy in Baghdad, killing the
driver and wounding more than a dozen others, US officials and witnesses said.

The suicide attack came a week after Turkey's parliament approved sending troops
to Iraq, a step opposed by many Iraqis.

Witnesses said a car raced towards the embassy and exploded. Three embassy
employees were slightly hurt, said Turkey's ambassador to Baghdad.


Another Challenge in Iraq: Giving Up Food Rations
by John Tierney, New York Times
October 12th, 2003

BAGHDAD, Iraq — The overhaul of welfare in America may seem complicated, but it
has been simple compared with the challenge in Iraq. In the United States, the
people who relied on public assistance were defined as the underclass. In Iraq,
they're the entire nation.

To Saddam Hussein, a culture of dependency was not a social problem but a
political plus. Father Saddam, as he liked to be called, provided citizens with
subsidized homes, cheap energy and, most important, free food. After
international sanctions were imposed on Iraq in 1990, he started a program that
now uses 300 government warehouses and more than 60,000 workers to deliver a
billion pounds of groceries every month — a basket of rations guaranteed to
every citizen, rich or poor.

American and Iraqi authorities are now struggling to get out of the
grocery-delivery business without letting anyone go hungry. They're trying to
find a politically practical way of replacing the rations with cash payments or
some version of food stamps. Planners would ultimately like to see the aid given
only to the needy, but for starters they would simply like to get all Iraqis
accustomed to shopping for themselves.

"We need to replace the food program and attack the dependency culture created
by Saddam Hussein," said Barham Salih, the prime minister of a Kurdish section
of northern Iraq, which also receives the rations. "This culture has become one
of the biggest obstacles to rebuilding Iraq. Everybody expects the U.S. to turn
on its supercomputer and make all of our problems go away, but we should be
learning to do things by ourselves."

You can get a sense of the challenge facing reformers by visiting Zayuna, one of
Baghdad's most affluent neighborhoods. While many Iraqis — 60 percent of the
population, by some estimates — depend heavily on the food rations, the
residents of Zayuna generally do not.

In fact, many of them disdain the items in the basket, which includes rice,
flour, beans, sugar, oil, salt, powdered milk, tea, soap and laundry detergent.
But most residents still make sure to collect — or have their servants collect —
their monthly rations from the program's agent operating in their neighborhood.

Then they take the items they don't want and drive to a roadside kiosk at the
nearby Thulatha market, where vendors are legally allowed to buy the rationed
groceries and resell them to less picky consumers. After the citizens sell their
government-issued groceries, they either pocket the cash or apply the proceeds
toward the purchase of better products available at the market, like olive oil
to replace the cheaper soy oil.

To an outsider watching people make these exchanges, it might seem odd for
people in Mercedeses and BMW's to be profiting from government food aid,
especially since the original justification for the aid has vanished. The
program began as an emergency response to United Nations trade sanctions, and
was later supplemented with provisions from the separate oil-for-food program of
the United Nations. Even though the sanctions have ended, the program is still
considered indispensable.

"It would be a disaster if the program ended," said Haidar Hassan, one of the
vendors at the market, and he was not merely speaking of his own business as a
middleman. "If the government did not give out all this rice, there would be a
shortage of rice in the market." He predicted the price of a kilogram (about two
pounds) would quadruple from its current price of 10 cents.

His clientele was similarly alarmed. "My economic situation is good, but even I
could not afford the new higher prices if they stopped the program," said Thaeir
Ezadden, a police captain whose salary had recently more than quintupled, to
$150 per month, thanks to the new pay scales instituted by American authorities.

Mr. Ezadden said he might be willing to go along with one change currently being
considered — giving everyone cash payments instead of rations — but only if it
was accompanied by more central planning.

"If they gave out money instead of food," he said, "the Americans would have to
establish an office in the Ministry of Trade to control all the food prices.
Otherwise businessmen would import food and make a profit with high prices. The
Americans should also give jobs to everyone who needs one."

Economists, while acknowledging the need for protecting consumers during the
transition, say that a market economy would provide food much more cheaply and
efficiently than the current government-run system. But the American and Iraqi
officials in charge of the program know that economists' arguments are not going
to assuage the fears of citizens who have forgotten how the market works.

"We want to phase out the rations program, but we must take into account the
concerns of our most vulnerable citizens," said Fakhrldin Rashan, the acting
officer in charge of the Ministry of Trade. "The transition to a different
system of payments must be done slowly."

Planners are considering gradually replacing some groceries with cash welfare
payments or some version of food stamps that could be redeemed at local markets.
Besides giving shoppers more choices, the change would also help Iraqi merchants
and farmers, because consumers would presumably buy more local fruits and
vegetables instead of relying on the many imported foods in their rations.

Mr. Rashan said no major changes in the program would take place before next
year, although one small part of it will be privatized soon. The drivers who now
deliver the food to government warehouses will essentially be given their trucks
and then paid as independent contractors instead of as government employees.

But that still leaves close to 20,000 other government employees in the food
program, plus another 45,000 distributors who dole out the food at neighborhood
storefronts. Any change in the program is sure to bring protests from the
affected workers as well as from citizens accustomed to having their shopping
done for them.

"People expected the Americans to come in and create a better rations system,"
said Robin Raphel, a State Department official who has advised Iraq's Trade
Ministry. "But we can never make the system work as well as it did when the
whole country was a command-and-control system run from the center, and even
then it was profoundly inefficient. We want to introduce market forces and get
people used to making their own decisions."

After Iraqis adjust to shopping for themselves with food stamps or welfare
payments, planners would like to wean the more affluent citizens from any kind
of aid. But no one expects American or Iraqi officials to take that step anytime

"We have to be very careful with our food program," said Mr. Rashan, of the
Trade Ministry. "We already have enough social and political problems in this
country. We don't want to create any more."

Mr. Rashan, incidentally, said that he himself has not been picking up rations
for the past several months, but not out of any ideological qualms.

"I've been so busy with the new responsibilities here that I haven't had time to
pick up the basket," he said. "But I hope I'll find the time next month."

Aid Workers Leaving Iraq, Fearing They Are Targets

by Ian Fisher and Elizabeth Becker, New York Times
October 12th, 2003

BAGHDAD, Iraq, Oct. 11 — A great majority of foreign aid workers in Iraq,
fearing they have become targets of the postwar violence, have quietly pulled
out of the country in the past month, leaving essential relief work to their
Iraqi colleagues and slowing the reconstruction effort.

Projects that have been abandoned, at least temporarily, because of the exodus
include efforts to dig village wells, repair electrical systems and refurbish
health clinics and local hospitals — all of which could bring much needed
services to hundreds of thousands of Iraqis.

The largest reduction in staff has been at the United Nations operation in Iraq,
which after two bombings at its main compound since August cut its work force to
35 from a peak of 600 in August.

Nearly every other relief organization has made some reductions, saying that
parts of Iraq are now highly risky, between unpredictable spasms of bombing and
shooting and high levels of street crime. There have been two killings of aid
workers since July, three grenade attacks on aid groups in the last month and at
least two carjackings.

Doctors Without Borders, founded by a French group, is weighing whether to
proceed with plans to build two more medical clinics, in addition to the three
it already runs. Another French group shut down a program for children. The
International Committee of the Red Cross has greatly reduced its system to help
Iraqis find missing relatives and has cut back on medical assistance to
hospitals and clinics.

The United Nations Development Program has put off major reconstruction of
electrical systems, and some groups, like Oxfam International, a private charity
concerned with fighting poverty, have pulled out their foreign workers

Charles Heatly, a spokesman for the American-led interim administration in Iraq,
played down the effect on the overall reconstruction in Iraq, saying the major
infrastructure repairs were being carried out by large contracting companies.

"Yes, its regrettable that some of the most accomplished NGO's, such as the
I.C.R.C., have scaled back their efforts," he said, referring to nongovernmental
organizations. "But they are still here and we are committed to continue to work
with them."

It is a difficult choice, aid groups say, whether to stay in Iraq now that most
of their work has shifted from immediate life-saving measures to longer-term
reconstruction projects that could nonetheless improve Iraqis' lives

The International Committee of the Red Cross, which is normally the first to
join these dangerous situations and the last to leave, has reduced its work
force to 30 from 130 at its peak. The committee, based in Geneva, has been
committed to Iraq since 1980, offering its services throughout the Persian Gulf
war of 1991, the ensuing years when Iraq was under United Nations sanctions, and
during the war last spring. But it began pulling out its staff after a Sri
Lankan technician was killed in July.

"We are absolutely committed to staying on and carrying on but we have to react
to the current situation," said Florian Westphal, a spokesman for the group in
Geneva. "One of the most regrettable consequences is that with fewer staff we
carry out fewer activities."

The group now restricts itself to providing help in medical emergencies and
visiting detainees and prisoners of war to ensure that they are afforded their
rights under the Geneva Conventions. "If we don't visit the detainees and help
them stay in touch with their relatives, no one else can do it," Mr. Westphal

The violence against foreigners continues. On Thursday, José Antonio Bernal
Gómez, the deputy intelligence officer at the Spanish Embassy, was assassinated
after he opened the door of his home to a man dressed as a Shiite cleric.

Normally proud to show off their achievements in the press and to donors, aid
workers have taken down signs in front of their offices and stickers off their
cars. They seldom speak to reporters. Few among them are willing to say how many
are based in the country, admitting only that more than half have left, leaving
mainly managers overseeing budgets and teams of Iraqi workers.

The aid workers who remain are taking greater precautions, traveling less,
increasing protection at their homes and offices, relying more on two-way radios
and staying away from the larger hotels. Most say they have not yet hired armed

They say the atmosphere can be deceptively calm. "You don't feel insecurity,"
said Thomas Dehermann, head of mission for Doctors Without Borders, which has
maintained a limited program in Iraq. "You feel like you are just working and —
boom! — it happens."

A further complication is the question of whether smaller aid groups, unlike the
United Nations, are actual targets for terror attacks, or mistaken as part of
the American occupation forces. "There is some confusion, which is the biggest
difficulty working here," Mr. Dehermann said. "Everybody is considered a
subcontractor working for the U.S., which is completely wrong."

Enfants du Monde, a French aid group, closed down a center for street children
after a dispute with some of the children led an angry neighbor to tell people
in the area that the group was part of the occupation forces. "After that, we
were quite afraid," said Michel Savel, the group's program coordinator.
Recently, the group scaled back in a telling way: Three of six foreign aid
workers left, one replaced with a full-time security adviser.

The biggest hole was caused by the flight of more than 550 United Nations

After the bombing on Aug. 19 of the United Nations headquarters here that killed
Sergio Vieira de Mello, the head of mission, and 21 other people, the
organization has come to rely on its 4,233 Iraqi employees to deliver essential
services. That includes bringing about 110,000 tons of food a month through the
World Food Program; about 3 million gallons of water a day to Baghdad and Basra
through the United Nations Children's Fund, and more than 550,000 tons of
fertilizers, herbicides and insecticides for winter crops.

"One of the fallouts of our evacuation is we lost some of our most skilled
professionals in the field," said William Orme, a spokesman for the United
Nations Development Program, which repairs infrastructure. "On the positive
side, we have Iraqis in positions of responsibility who are able to carry out
the bulk of the immediate repairs."

Aid officials said Iraqis were more than capable of assuming greater roles in
their country's recovery. The country director for CARE, Margaret Hassan, is an
Iraqi citizen who oversees 8 foreign staff members and 60 Iraqis.

"Even though security remains a major concern — not only for foreigners but for
Iraqis — I do think the rebuilding of Iraq must be done overwhelmingly by
Iraqis," said Peter D. Bell, president of CARE U.S.A.

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