arch/ive/ief (2000 - 2005)

1. Geneva Convention

The public health consequences of war go far beyond the direct casualties caused by weapons. Water, for example, is essential to prevent health problems including malnutrition, gastro-intestinal infections and other communicable diseases. Without access to safe water sources the civilian population, especially children, are at risk. Therefore Protocol II of the Geneva Conventions explicitly states: "It is prohibited to attack, destroy, remove or render useless objects indispensable to the survival of the civilian population, such as foodstuffs, agricultural areas for the production of foodstuffs, crops, livestock, drinking
water installations and supplies (…)." The pre-war U.N. "Likely Humanitarian
Scenarios" report had already warned that damage to the electricity network would affect water supply and sanitation giving rise to the need for some 39 percent of the population to be provided with potable water. It added that a high number of indirect casualties might be because the outbreak of diseases in epidemic proportions was very likely. (Campaign Against Sanctions on Iraq "Confidential UN Document Predicts Humanitarian Emergency in Event of War on Iraq" Press Release, 7 January 2003)

2. 1991 Gulf War

Most civilian casualties in armed conflicts are the result of the destruction of civilian infrastructure that is essential for people's health. This was also the case for the first Gulf War that, according to the first post-war U.N. mission, had caused "apocalyptic damage" to the infrastructure and had reduced the country to "the pre-industrial age." (Roger Normand "Special Report: Water Under Siege In Iraq. US/UK Military Forces Risk Committing War Crimes by Depriving Civilians of Safe Water" The Center for Economic and Social Rights, April 2003)

The vast majority of deaths in 1991 were caused by the destruction of the electric power grid and the ensuing collapse of the public health, water and sanitation systems, leading to outbreaks of dysentery, cholera, and other water-borne diseases. Therefore, one of the most comprehensive casualty assessments of the first Gulf War concludes that "the lethality of indirect effects of warfare can be much greater than the direct lethality of the weapons themselves." (Beth Osborne Daponte, M.A. "A Case Study in Estimating Casualties from War and Its Aftermath: The 1991 Persian Gulf War" 1993)

3. Attacks on infrastructure

3.1. Basra was the first city that suffered a humanitarian crisis because of the U.S.-British belligerence. On March 21, air raids destroyed high voltage lines and knocked out Basra's electrical power. That in turn disabled Basra's water and sanitation systems, including the Wafa' Al Qaed Water Pumping Station, which pumps water from the Shatt al-Arab river to five water treatment plants that supply piped water to over 60 percent of Basra's 1.5 million residents. (Roger Normand "Special Report: Water Under Siege In Iraq. US/UK Military Forces Risk Committing War Crimes by Depriving Civilians of Safe Water" The Center for Economic and Social Rights, April 2003)
After one month of war, water shortage was still severe and water was reportedly sold on the black market at USD 1 per 1.5 liter bottle. ("Iraq: Basra's pivotal issue - water" UN Office for the Coordination of Humanitarian Affairs Integrated Regional Information Network, 18 April 2003) The International Committee of the Red Cross (ICRC) successfully restored running water to some of the population on 2 April and continued to supply water trucks. At the end of April, water and electricity supplies in Basra were still at only 60 percent of their prewar levels. (International Committee of the Red Cross "ICRC: Iraq is at a crucial stage" 20 April 2003)

Apparently, the power and water supply of other cities were also targeted by the attacks. By 31 March, half the 1.2 million people in the beleaguered city lacked water. People reported that they were reduced to drinking "garden water" normally used for irrigation, which is not safe to wash in, let alone drink. Humanitarian agencies warned that the population of Basra, especially the young and the weak suffering the effects of years of economic sanctions, could be at risk of potentially fatal disease from drinking contaminated water.
Amnesty International "Iraq: Civilians under fire - April 2003" AI Index: MDE14/071/2003

On April 2, the ICRC reported that "entire towns and suburbs have now been without piped water for about a week, including several district towns north of Dhi Qar and Najaf but also towns south of Basra such as Al-Zubayr and Safwan." (ICRC, Daily Bulletin, 2 April 2003 )
In Nasiriyah, the water treatment plant was reported to be working only six hours a day as of April 20 and water treatment chemicals were in short supply. (UNICEF Iraq briefing note 20 April 2003)

3.2. On April 3, power to 90 percent of Baghdad was cut because of the damage to the Al-Doura power station during the American capture of Saddam International Airport. (Anthony Shadid "Blackout Increases Foreboding, Darkness Stills City Bracing for Chaos" Washington Post, 4 April 2003) One week later, after the capture of Baghdad by the U.S. troops, the ICRC reported that power cuts have continued ever since. At that time, major water treatment plants in the city were operational at about only 40-50 percent of their normal capacity. After the damage resulting from military operations and waves of vandalism and looting, the Baghdad water authorities reported the loss of all their assets and warehouse materials, including all spare parts, vehicles and other equipment. ("ICRC: The medical system of Baghdad totally disrupted by insecurity and looting" 12 April 2003)

3.3. A spokesperson of the World Health Organization warned already on April 6 that Iraq was facing the risk of an outbreak of cholera or other infectious illnesses, as clean drinking water was scarce and hospitals were overwhelmed. ("Iraq at risk of cholera epidemic" AFP, 7 April 2003) This assessment was echoed by UNICEF on April 21 when they reported a huge increase in child diarrhoeal cases in Baghdad. (United Nations "UN relief agencies praised Iraqi health workers" 21 April 2003) Although water was being supplied to most parts of Baghdad by the end of April, the sanitation situation remained extremely critical and threatened public health. (United Nations "UN relief agencies report slow improvement in Iraq, but situation still 'precarious'" 22 April 2003)

4. Medical targets - Targeting ambulances and medical infrastructure

Medical infrastructure and personnel enjoys particular protection under the rules of war as laid down in the Geneva Law. Article 12 of Protocol II states: "Medical units shall be respected and protected at all times and shall not be the object of attack," while Article 15 adds that "Civilian medical personnel shall be respected and protected." Article 21 extends the protection also to medical vehicles, including ambulances.

4.1. There are disturbing reports that ambulances have deliberately been fired upon by U.S. troops.
On April 9, MATW doctors Geert Van Moorter and Harrie Dewitte were at the Saddam Center for Plastic Surgery, which was functioning as a frontline hospital for the war-wounded. They witnessed how one of their ambulances that had left to transport patients to another hospital came back after a couple of minutes after it had been under fire by U.S. troops. Two of the patients it transported were dead and the driver and his co-driver had gunshot wounds.
When Dr. Van Moorter went up to a U.S. officer to denounce their attitude, he answered that "the ambulance could contain explosives." ( "US troops fire on ambulance, two killed" AFP, 10 April 2003; A resident of Najaf is also quoted in an April 29 AFP report saying that "Why did the Americans target civilians? They even hit ambulances trying to rescue those injured and killed five medics." in "US cluster bombing leaves Iraqi city angry over dead, maimed" AFP, 29 April 2003)

A similar justification for targeting civilian and medical vehicles alike was reportedly also given by Colonel Bryan P.McCoy, the commander of the Third Marine Battalion of the 4th Regiment. When distraught soldiers were complaining that they were uncomfortable shooting at civilians, the colonel countered that the Iraqis were using civilians to kill marines, that "soldiers were being disguised as civilians, and that ambulances were perpetrating terrorist
attacks." ( "Des soldats, désemparés, disent : "Je ne suis pas préparé à ça, je ne suis pas venu ici pour tirer sur des civils." Le colonel oppose que les Irakiens utilisent les habitants pour tuer des marines, que "des soldats sont déguisés en civils, que des ambulances commettent des attentats." Michel Guerrin "J'ai vu des marines américains tuer des civils" Le Monde, April 13, 2003)

4.2. Several hospitals sustained severe damage in air raids. On April 2, for example, U.S. aircraft hit a building opposite the Red Crescent maternity hospital in Baghdad and the blast was so strong that the hospital's roof collapsed. The maternity hospital is part of a Red Crescent compound that also includes their headquarters and a surgical hospital. (IFRC "Red Crescent maternity hospital damaged in attack" 3 April 2003) Patients and at least three doctors and nurses working at the hospital were wounded. (Simon Jeffery "Baghdad hospital bombed" The Guardian, 2 April 2003)

The damage to health infrastructure outside the major urban centers is still not fully assessed but probably it is considerable. Members of the Iraq Peace Team reported that a hospital in Rutbah, near the border with Syria, was bombed on March 26. The anti-war activists who were leaving the country said they saw no significant Iraqi military presence near the hospital or elsewhere in the town. (Charles Hanley "American Peace Activists Confirm Iraqi Hospital Bombed" Associated Press, 31March, 2003)

In Nasiriyah the Primary Health Care Department and Department of Health warehouses were reported to be destroyed by a missile. These warehouses held a six month stock of health supplies including high protein biscuits. (UNICEF Iraq briefing note 20 Apr 2003)

5. The plight of hospitals under U.S. occupation

Whatever the involvement of the occupying forces in the widespread looting and destruction is, they are responsible for the medical infrastructure in the territories under their control. As soon as Baghdad was under U.S. control, "the medical system of Baghdad has virtually collapsed" the ICRC alarmingly wrote on April 11. (International Committee of the Red Cross "The medical system in Baghdad has virtually collapsed" 11 April 2003)
The same day a team of the ICRC was able to assess the situation of the hospitals in Baghdad. (International Committee of the Red Cross "ICRC: The medical system of Baghdad totally disrupted by insecurity and looting" 12 April 2003)
The Medical City complex-that consists of four hospitals-was in total chaos. The triage and emergency units were completely disorganized and there was no ambulance service. No new patients were being admitted. Only a few surgeons and one or two nurses were present in the hospitals, each with 600 beds. There were no administrative, cleaning or kitchen staff. And there were still 300 patients to care for. Only three days before, the ICRC medical coordinator had also visited this hospital's triage and emergency center, which could handle 100 patients at any one time, and found "that the complex was a perfect example of mass casualty management." Also the Al Kindi hospital, still working efficiently on April 8, was in total chaos. There was only one medical doctor present and no surgeons. Some patients were found lying on the floor. Medical and other supplies were scattered all over the place.

On April 12, the ICRC team reports that the Yarmouk Hospital, which had been treating patients at a rate of 100 per hour during the invasion of Baghdad, (ICRC "Baghdad Yarmouk hospital: one hundred patients an hour" 6 April 2003) was working only as a first-aid post. A rocket had hit the third floor, which was totally destroyed, and two of the three generators were damaged. Corpses were piled in the entrance hall before being buried in the hospital grounds. The doctors and staff had been able to salvage half of the equipment while looters were carrying off furniture. The 500-bed Al Karama hospital, on the other hand, had been protected from looting by the civilian population and its staff were even able to recover whatever equipment and supplies that were left at the Al Khark hospital for safekeeping on their premises. The 125-bed Alwiya Children's hospital, the main pediatric medical facility in Baghdad, had been protected from looting by the presence of armed medical staff living in the hospital. The wards were closed, but some 100 consultations per day were being performed for out-patients. Also here the ICRC was impressed by the staff who "were defending the hospital with courage and conviction." In Ibn Nafis Hospital, one of the few hospitals still functioning in Baghdad, the existing team had been increased in number by several surgeons from looted hospitals. Non-medical services such as cleaning, however, were very poor. The Al Numan Hospital was intact and had been very well protected by the civilian population. Although the surgical staff were still on the site, the prevailing insecurity made access very difficult for patients. The Ibn Al Haythem Eye Hospital and Abduker Military Hospital were closed after being looted. Also at Rashad and Ibn Rushad Psychiatric Hospitals no treatment was available for patients. (International Committee of the Red Cross "Yarmouk hospital: Corpses were piled in the entrance hall before being buried in the hospital grounds" 13 April 2003)

On April 17, the ICRC still reported a dire situation in Baghdad's hospitals. In Al-Rashad Psychiatric Hospital, for example, waves of looters had descended on the facility, burning everything that was not stolen. The hospital director reported that some patients had been raped. The 1,050 patients fled the hospital and only 300 patients had returned but their living conditions were dismal. (International Committee of the Red Cross "ICRC: Dire situation in hospitals" 17 April 2003)
On April 19, the Adnan Specialist Hospital was forced to shut down the only five of its 25 operating theatres still working after running out of oxygen and anesthetics. Dr Haifa Mohammed Ali, senior anesthetist at the hospital testified that the U.S. troops refused to protect the hospital against looters. A small contingent of marines was eventually sent after the worst looting but they were withdrawn a few days later. (Mark Baker "Hundreds are dying who should not die" The Age, 21 April 2003)
UNICEF reported that on April 21 only seven percent of the Al-Salam Primary Health Care Center's staff was working. They were assisted, however, by volunteers from the local community. The hospital was experiencing a shortage of water, anti-diarrhoeal drugs and injectable and oral antibiotics and suffered from bad sewage drainage. Because other hospitals in the area were not operational it had to serve more than 100,000 people, more than double its normal coverage. (UNICEF, Iraq briefing note, 21 Apr 2003)
At the Saddam City Hospital in northern Baghdad the morgue was reported to be full and there was not enough power to preserve the corpses already piled inside. (Mark Baker "Hundreds are dying who should not die" The Age, 21 April 2003)
Only on April 22, UNICEF reported that health services were no longer deteriorating and the situation started to stabilize. Its spokesman, Geoffrey Keele warned, however, that things had stabilized at a very low level that left the most vulnerable section of Iraqi society, including its children, at great risk. (United Nations "UN relief agencies report slow improvement in Iraq, but situation still 'precarious'" 22 April 2003)

6. Endangering and hindering health personnel

The inaccessibility of the few medical facilities that were still open was not only the result of the population's supposed lawlessness. The U.S. occupying forces reportedly prevented patients from seeking treatment and health personnel from moving around. On April 11, MATW doctor Geert Van Moorter reported from Baghdad: "Medical personnel do not even dare to ask permission from American checkpoints to bring the wounded to the hospital, as any Iraqi who approaches U.S. soldiers risks to be shot. They would rather ask us, the foreigners, to negotiate with the U.S.-troops for patients to be allowed to pass."
Amnesty International illustrated the inability of ambulances and other vehicles to move freely with the report that on April 10 around 20 bodies, including those of children, were still strewn on the road between al-Doura and the airport, days after they were killed. At that time the road was already controlled by U.S. forces. (Amnesty International "Iraq: Looting, lawlessness and humanitarian consequences" 11 April 2003, AI Index: MDE14/085/2003)
Medical crews were reportedly shot at by U.S. troops when they tried to retrieve the injured after the Americans killed 13 protesters in the city of Fallujah on April 28. This was confirmed by Dr. Ahmed Ghanim al-Ali, director of Fallujah General Hospital. ("U.S. soldiers fire on Iraqi protesters; hospital chief says 13 Iraqis are dead" Associated Press, 29 April 2003)

Article 15 of Protocol II states, however, that "the occupying power shall afford civilian medical personnel in occupied territories every assistance to enable them to perform, to the best of their ability, their humanitarian functions." Moreover, they should give health personnel access "to any place where their services are essential."
Equally alarming is the U.S. and British troops' practice of treating humanitarian aid as an exercise in public relations. This raises concerns of effectiveness and appropriateness, but also jeopardizes aid workers, including many health professionals. (The Christian Science Monitor reported that U.S. Troops built a "very photogenic" playground in Umm Qasr while children were still dying from communicable diseases because of the interrupted water supply. Sarah Kenyon Lischer "Humanitarian aid is not a military business" Christian Science Monitor, 15 April 2003; The Jordan Times fears that the military's humanitarian efforts would be ineffective because "Iraqis know well that, if it weren't for those very US-British forces, they wouldn't be in need and wouldn't find themselves in want of food, water and medicine in the first place." "The militarization of humanitarian aid" The Jordan Times, 31 March 2003)

The ICRC therefore rejects any direct involvement of military forces in relief operations "as this would or could, in the minds of the authorities and the population, associate humanitarian organizations with political or military objectives that go beyond humanitarian concerns." (Roger Normand "Special Report: Water Under Siege In Iraq. US/UK Military Forces Risk Committing War Crimes by Depriving Civilians of Safe Water" The Center for Economic and Social Rights, April 2003)
The ICRC's concern is not baseless as some reports of military relief operations in occupied areas confirmed that they were conducted in a hostile atmosphere. (Burhan Wazir "Jubilation turns to hate as aid arrives" The Guardian, 27 March 2003 )

Arab News war correspondent Essam Al-Ghalib described how during one of these relief operations in Najaf "a soldier was pointing at the crowd ordering them away from the fence separating the food distributors from the hungry crowd. Every time the soldier passed an order on to the civilians or those arriving in vehicles, he aggressively pointed his 50-caliber truck-mounted machine gun at them, lowering his head to see as though taking aim." When the reporter approached the soldier and asked why he was pointing his machine gun at unarmed civilians he answered that they might be suicide bombers. (Essam Al-Ghalib "Mounting Iraqi civilian casualties, Is it war against the Iraqi people?" Arab News, 8 April 2003)

Even before the war, the U.S. had already stated its intention to subject civilian humanitarian efforts to military authority. Its Office of Reconstruction and Humanitarian Affairs (ORHA) that is supposed to oversee the reconstruction of Iraq reports to the Department of Defense. It includes a Kuwait-based Humanitarian Operations Center staffed by U.S., Kuwaiti and British military staff. The Pentagon requires aid agencies to coordinate with the HOC and to wear identification tags issued by these military authorities.
Many relief and aid agencies, including health NGOs, have already complained that the dangers faced by relief workers in the field are multiplied by the insistence of the U.S. government that NGOs are forced to work under Department of Defense jurisdiction. (Carol Giacomo "Aid groups oppose Pentagon control of aid effort" Reuters, 2 April 2003; Shanta Bryant Gyan "Statement on Military Control of Iraq Relief; Reconstruction" InterAction, 3 April 2003)
Some aid organizations, however, are expected to comply in exchange for valuable contracts and international visibility for their organizations, relinquishing any pretense of neutrality and impartiality. (Sarah Kenyon Lischer "Humanitarian aid is not a military business" Christian Science Monitor, 15 April 2003)

7. Heroic Iraqi health workers

The Iraqi health workers' commitment to ensuring health care despite the war contrasts sharply with the carelessness of the occupying forces. The WHO said it was "extremely impressed by thelevel of dedication the Iraqi health staff bring to their work even in these circumstances." WHO spokesperson Fadela Chaib said that the dedication of doctors, nurses and support staff including cleaners, cooks, maintenance workers and drivers was saving lives. (United Nations "UN relief agencies praised Iraqi health workers" 21 April 2003) In Basra, Dr Dahham Falih al-Musa, a senior house officer at the Basra Teaching Hospital, said there was a great team spirit among the medical staff. Even during the height of the fighting, the hospital remained operational although its director, Dr Akram Abid Hasan, lost 10 family members including two sons, two daughters, his mother, brother and a sister when a bomb or missile struck his home. Two other senior doctors at the hospital also lost children and wives in the war. ("Iraq: Conditions in Basra's main hospital still dire" UN Office for the Coordination of Humanitarian Affairs Integrated Regional Information Network, 17 April 2003)

The U.N. agency's high esteem for the Iraqi health workers was shared by MATW's medical team in Baghdad and several journalists. Robert Fisk, for example, describes his meeting with Dr Khaldoun al-Baeri, the hospital director and chief surgeon of Baghdad's Adnan Khairallah Martyr Hospital: "Dr Baeri speaks like a sleepwalker, trying to describe how difficult it is to stop a wounded man or woman from suffocating when they have been wounded in the thorax
explaining that after four operations to extract metal from the brains of his patients, he is almost too tired to think, let alone in English. As I leave him, he tells me that he does not know where his family is. 'Our house was hit and my neighbors sent a message to tell me they sent them away somewhere. I do not know where. I have two little girls, they are twins, and I told them they must be brave because their father had to work night and day at the hospital and they mustn't cry because I have to work for humanity. And now I have no idea where they are.' Then Dr Baeri choked on his words and began to cry and could not say goodbye." (Robert Fisk "Final proof that war is about the failure of the human spirit" The Independent, 10 April 2003)

8. Mounting humanitarian concerns Amnesty International AI Index: MDE14/085/2003

Millions of people in Iraq face grave dangers to their health, with many hospitals unable to cope with the number of war casualties and sick, and indications that serious water-spread diseases such as cholera are on the rise owing to the scarcity in some areas of clean water. Humanitarian agencies have reported that access to healthcare and medicines is increasingly difficult as medical stocks run low and disorder in the streets prevents the movement of health workers and ambulances.
"With the breakdown of law and order in Iraq, the situation now is extremely critical," said David Wilmhurst of the UN Humanitarian Coordinator for Iraq (UNHCI) on 9 April. "The longer the situation remains out of control, the more difficult it will be to start humanitarian relief operations."

On 6 April UN relief agencies warned that a health crisis faced the five million inhabitants of Baghdad, with hospitals overwhelmed and infrastructure devastated. World Health Organisation (WHO) and ICRC officials confirmed that the capital's hospitals were struggling to cope. The ICRC reported that some areas of Baghdad had no water at all. A UNICEF official said they were particularly worried about the impact on Baghdad's children, almost half the city's population. UNICEF also said that 100,000 children in Basra were threatened with serious illness because the water treatment plant had stopped functioning.
The same day the ICRC reported that emergency services were not being provided by the hospital in Umm Qasr and patients could not travel safely to Basra for treatment. It also said that the water situation in Umm Qasr remained a concern, and that there was no fuel available for pumps. On 7 April WHO officials warned that Iraq was facing an outbreak of cholera and other infectious diseases as clean drinking water was scarce. On 8 April an ICRC spokeswoman told a news briefing that hospitals had reached their limit and that the main surgical hospitals and water treatment plants were relying solely on back-up generators. She described it as "an untenable situation".

On 8 April the ICRC reported that in Saddam City, the flow of tap water was cut by half, and that lack of water and electricity supplies had badly affected Saddam Medical Centre. It reported acute water shortages in Kerbala, al-Najaf and Basra. The UK's Department for International Development said that it understood there were water shortages in other parts of central Iraq, including Abu Ghraib, Mahmudiya, al-Hilla and al-Anbar. In al-Nasiriya, residents were reportedly out on the streets searching for water. The ICRC said it was maintaining some water supplies to hospitals and areas in particular need.

By 9 April the ICRC was describing the humanitarian situation in Baghdad as "critical", particularly as health, power and water workers could not reach their workplaces safely, and many medical centres lacked water and electricity. One of the only international aid organizations working in Baghdad, it said it was temporarily suspending its humanitarian work in the capital because of the "chaotic and unpredictable" atmosphere. The previous day a Canadian ICRC worker had been killed when his car was hit in crossfire in Baghdad.
On 10 April the ICRC resumed work in the capital but reported that al-Kindi hospital in Baghdad had been ransacked and that street violence and looting had forced the closure of others. US troops called in when looters stole two ambulances and medicines from the hospital replied that they had no orders to intervene, reported AFP. WHO officials said they were "extremely concerned that the apparent lack of law and order in Baghdad will have a very serious impact on health and healthcare in the Iraqi capital."
The inability of ambulances and other vehicles to move freely in the capital was highlighted on 10 April by an AFP photographer, who reported that around 20 bodies, including those of children, were still strewn on the road between al-Dora and the airport, days after they were killed. The road is controlled by US forces.