October 19, 2013
During my time as the director of the World Health Organisation's (WHO) programme in Iraq between 2001 and 2003, the WHO, together with other agencies, were aware of the reports of abnormal rates of health problems, such as cancers and birth defects, in southern Iraq. In the 1991 Gulf War, the fighting had been concentrated in the south and it was notable that reports of illnesses were far more prevalent in this region. A decade on, and a long overdue study by the Iraqi Ministry of Health into the prevalence of congenital birth defects has been undertaken in collaboration with the WHO; however its interim results have puzzled observers.
The institutional capacity that has finally allowed the study to take place should have been developed with funds from the Oil For Food Programme (OFP) in 2001. OFP money was required as the cost of the proposed work far exceeded the WHO's regular budget for Iraq at the time. Unfortunately, all projects funded through the OFP were subject to a complex process that required the final approval of the United Nations Security Council. Frustratingly, any project that proposed to investigate abnormal rates of birth defects in southern Iraq and their relation, if any, to environmental contamination, never got through the Security Council's approval process.
Before the 2003 invasion, the cynicism demonstrated by certain member states of the Security Council towards the post-conflict health conditions in southern Iraq was appalling. Following regime change, the attitude of the Coalition Provisional Authority just added arrogance to the cynicism. The funds from the OFP belonged to the Iraqi people, yet the Security Council responded with little alacrity to any attempt to release Iraqi money to finance research into the legacy of conflict on cancer rates in the south.
Political sensitivity over the legacy of the use of depleted uranium munitions may have helped catalyse Security Council objections to the research into the public health legacy of the conflict. Recent estimates for the cost of managing sites known to be contaminated with depleted uranium run to tens of millions of dollars, yet focusing solely on depleted uranium runs the risk of ignoring many other environmental risk factors.
A decade after Saddam's fall and many toxic remnants of war are still present in the environment. When in 2003 the war came to the areas where people live, work and play - the exposure risks to civilians from all military-origin contamination, be they heavy metals, explosive residues, building rubble, smokes and obscurants were markedly increased.
The interim report by the Iraqi Ministry of Health, which was published without fanfare on the WHO website on September 11th, had been widely expected to confirm that rates of congenital birth defects in Iraq were not only high but higher in areas subject to heavy fighting in 1991 and 2003. Instead it reported the opposite - that rates in cities such as Fallujah and Basrah are around half that typical of high income countries.
Puzzlingly, the interim findings in the study run counter to the consistent reports of medical professionals across Iraq. They also stand in stark contrast to the views expressed by Ministry of Health officials interviewed by the BBC earlier this year. In their opinion, there was a clear link between areas subject to heavy fighting and an increased incidence of birth defects. If confirmed, such findings could have significant political ramifications for not only Iraq but for post-conflict civilian health in general. As a result, the study has received considerable attention, with more than 53,000 people signing a Change.org petition calling for release of the study data and for its independent peer-review.
A number of experts have now come forward to question the study's methodology and the robustness of the peer-review process, most recently in the respected medical journal The Lancet. Critics have questioned the decision to undertake a household survey, instead of collating hospital records and challenged the anonymous authors on the lack of information concerning the selection criteria for areas included in the survey.
While the interim report does acknowledge some limitations, the ongoing instability in Iraq and the intensely political nature of the study raise concerns over the politicisation of the research. I believe that the only way to resolve such concerns and ensure the best outcome for the Iraqi people is for the Ministry of Health and WHO to be more transparent than they have been thus far. Lessons must be learned from the history of public health research in Iraq.
The politicisation of Iraq's public health research under the OFP should serve as a reminder that the WHO is nothing more than a reflection of the collective will of its member states. This collective will is often greatly influenced by those nations that exercise global power and, while the structure of the WHO does not necessarily reflect this influence, the decisions it implements certainly do.
It is quite unlikely that the WHO, as a professional organisation, has ever tried to block or downplay research. However, it is clear that the imbalances that exist in its funding, particularly for those public health projects that go beyond its regular country budgets, are open to state influence. In a system in which the financing is so disparate among member states, it is obvious that those who influence the purse influence the spend.
The agency continues to play a crucial role globally, thus it is important for the WHO to be transparent in all cases, as it was constitutionally created to be. The need for transparency is particularly acute in post-conflict public health research and the WHO has an important role to play in ensuring that its research partners pursue open, robust, science.
The people of Iraq, as with all communities caught up in war deserve to know whether environmental contamination from conflict presents a long-term threat to their health. Their governments, and those of the states that contributed to the damage, share an obligation with the international community as a whole in ensuring that the protection of civilians during and after conflict remains paramount.