This document reviews child and infant mortality in Iraq over a ten year period through multiple studies. The first study from 1992 found infant mortality increased nearly 3 times after the Gulf War. Later studies in the mid-1990s and 1999 also found elevated mortality rates and estimated hundreds of thousands of excess deaths among Iraqi children due to factors like war destruction, sanctions limiting access to food and medicines, and collapse of infrastructure like power, water, and healthcare systems. While sanctions may have had an independent effect on mortality, the combination of war, sanctions, and their impacts on society likely contributed to the public health crisis.

1. Child and Infant Mortality in IRAQ-A
Ten Year Review
 Kayvon Alizadeh
M.D.
 Department of
General Surgery
 University of
Vermont
 December 1st
,
2004

2. Objectives….
 To review child and infant mortality and
excess deaths in Iraq before and after Gulf
war and sanctions
 Causes:
Sanctions
War
other

3. Articles…
3 different household cross-sectional surveys
First paper done immediately after Gulf war.
Second study performed in mid 1990s
Third study sampled Iraqi infant death rate in
1999, with mention of excess deaths since gulf
war.
2 papers discussing possible causes:
Immediate effects of war-Harvard study team.
Multivariate proportional hazards analysis-A
Sanctions model.

4. Brief background on IRAQ..
 Prior to gulf war, industrialized country.
 Population with access to safe drinking water up
from 66% in 1975 to 87% in 1986.
 Free primary health care reached 93% of
population1
 Mostly urban population(43% in 1960 to 73%
in 1988).
 Highly urbanized depending on electric power
for water purification, sewage treatment and
functioning of hospitals.1
 Poor record keeping of Vital statistics

5. Gulf War and Infant/Child Mortality in
IRAQ by Alberto Ascherio et al2
..
 Paper published Sept 1992 NEJM
 METHODS:
 Design:
 Multi stage cross-sectional interview survey study
 Population: Country divided into 19 regional groups
constitute Republic of Iraq
 Further divided into urban and rural areas
 Expanded Immunization program used for sampling
regions
 Areas within regions selected based on probability of
being in sample proportional to size of population
 Total 271 clusters of 25-30 households

6. Methods continued.
 Data collection
 Interviewers were primarily Jordanian
students/doctors fluent in English/Arabic
 Supervised by public health professional
 Of the 31 interviewers 21 were women
 In each household all women15-49 yrs of age
reported at least one birth after Jan 1985
 Info pertaining to death, current age, maternal
education. If death reported cause was
recorded.

7. Methods continued..
 Data and Analysis:
 Neonatal<1month
 Post-neonatal 1-12months
 Child 12 to <60 months
 16,172 live births, 803 deaths.
 96 children excluded year of birth/death
missing(35 of 96 were deaths)

8. Methods continued..
 To assess War/sanctions, took ratio of mortality
before/after Jan 1 1991.
 Confidence intervals calculated with Poisson
distribution.
 Lift tables to calculate probabilities of dying
 Number of excess deaths based on 18.9 Million
population of 1990 census/18% under age of 5,
growth rate of 3.5% and crude birth rate of 43/1000
 Poisson regression models used to adjust relative
mortality

9. Ascherio et al.

10. Results..
 By life Table: Before Jan1 1991: Risk of dying first
year or first five years was 32.5 and 43.2 per 1000
respectively. After Jan 1 1991: Risk was 92.7 and
128.5 per 1000 respectively.
 Age-adjusted relative mortality after war was 3.2(2.8-
3.7)
 Calculated an excess of 46,900 deaths between Jan-
Aug of 1991
 Adjusting for region of residence, maternal education
RR 3.4(2.9-3.9).

11. Discussion
 Internal validity: Omission of 35 deaths most
of which occurred before war. Tend to
underestimate pre-war mortality rate and
increase RR.
 External validity: Merely a sample of
population. Excess deaths based on stable
population of 1990(dead women from
bombings/war), as well as a stable fertility
rate.

12. Health of Baghdad’s Children by
Zaidi, Sarah et al3
..
 Published in Lancet 1995
 Similar design as previous study
 Cross-sectional Survey; random sample of 25
clusters of neighborhoods of Baghdad
 Again Women 15-49yrs of age with at least
one birth after Jan 1985.
 Data:
 2120 children 330 deaths.
 567,000 excess deaths since August 1990.

14. Limitations of study..
 Much smaller sample size
 Variation in Pre war mortality with infant
mortality rate at 80 deaths per 1000 births.
 No mention of international team or quality
assessment.
 No mention of questions asked or
interviewers.
 Excess death estimate based on 1990
population, and this increased in mortality
rate. No mention of fertility rate.

15. Sanctions and Mortality in IRAQ
Mohamed Ali, Iqbal Shah4,5
.
 Published May 2000 in Lancet
 United Nation Children’s Fund (UNICEF) in
partnership with the Government of Iraq
 METHODS:
 Design:
 Multi stage cross-sectional survey in two different
regions of Iraq: Center/South and Autonomous
regions
 Population:
 Similar to NE design. Three stages with each stage
further subdividing area by Probability proportion-to-
size (PPS)
 Cluster design

16. Methods continued..
 24,000 households in center/south, 16,000
households in autonomous region
 15-49yr old female with at least one birth from 1974-
1999
 Questionnaire: based on Demographic and Health
Surveys (DHS).
 Supervisors/Interviewers trained in DHS
questionnaire
 186 staff; 170 interviewers 16 supervisors
 Great care was taken to obtain high quality data
 Supervisor checked sample household coverage
 Internal consistency with respect to responses.

17. Methods continued…
 Questionnaire primarily used to obtain
birth/death history
 Synthetic cohort created. Life table used to
estimate mortality rate.
 Infant mortality rate 0-1yr
 Child mortality rate <5yrs of age

18. Results…
• 23,920 households in
center/south covered
with 21,048 ever-
married women 15-49
• 15,942 households
covered in
autonomous region
with 14,035
completed
questionnaires

21. Results continued..
 Excess deaths:
 Developed life tables calculated annual
mortality
 Hypothetical mortality rates were then
calculated assuming: 1. rates stayed the
same as they were pre Gulf war, or 2.
continued to decline by regression line.
 Fertility rates from survey data. Used to
calculate annual fertility rates (Split and fitted
values).
 Births multiplied by annual deaths.

24. Discussion
 Internal Validity: Significant checks for consistency;
pretest given; many supervisors; multi-national
approach
 External Validity: Merely a cross-sectional approach,
Validity of study relies on population census-no
mention of its validity.
 Validity of fertility rates
 Significant mathematical estimations made with
developing annual number of births/deaths {Brass
and Blacker for mortality, and Carrier and Hobcraft}

25. Causes?
 Harvard Study team1
: 10 members including 2 Arabic
speaking visited 11 major cities from April 27 to May
6 1991(4 months after 120,000 bombing sorties were
carried out).
 Visited 19 health centers/hospitals, 11 electrical
generating plants, 10 substations, 3 water treatment
plants and 4 sewage-treatment plants.
 After bombing only 2 of 20 power plants were
functional (producing only 4% of prewar power). By
May 1991 only had 23% of power available.

26. Causes continued..
 Water purification system essentially demolished by
destruction of power plants
 None of health care facilities used piped water;
considered unsafe.
 Raw sewage controlled by power plants: “In
neighborhoods in both Basra and Baghdad, whole
streets were blocked by pools of foul-smelling water.”
 Significant increases in gastroenteritis/typhoid and
cholera
 Harvard study had cause of death on 583
children(76%): Age-adjusted for diarrhea up from 2.1
per 1000 person-years to 11.9.

27. Causes continued
 Malnutrition: Mothers repeatedly complained of
scarcity of infant formula. Government rations
insufficient
 Food and Agricultural Organization (FAO), stated that
the percentage of low birth-weight babies had
increased from 4% in 1994 to 25% in 1997.
 Only 50% of urban pop and 33% or rural south/centre
had access to drinking water as late as 1998.
 “Oil for food” program, instituted in 1995. Ali’s data
shows decline in infant mortality from 1995 on(by life
table). Author states that greater amount and
efficiency of allocations to this less developed area

28. Causes continued..
 Health care services. Director of Health stated 20 hospitals
and 38 health care services destroyed/severely damaged from
war
 Basra Teaching hospital was evacuated on Jan 26th
after bomb
left a crater in hospital garden, almost every window shattered,
ceilings collapsed, ICU in ruins.
 Many facilities without proper refrigeration to store
vaccines/medicines.
 Of the 16 hospitals visited 8 reported complete lack of running
water or inadequate water supplies
 Electrical problems prevalent throughout hospitals(5 of 16
hospitals visited had frequent electrical failures) “At Saddam
Maternity hosp in Baghdad, director Dr. W.A. Mahmoud, told
them of the difficulties of performing cesarean sections by
lamplight.”

29. Sanction Effect?
 Daponte and Garfield6
, published in American Journal
of Public Health April 2000
 Utilized Harvard study team data to compare two
different time periods; before (Jan 1985-Aug 1990)
and after sanctions (Aug 1990 to Jan 1991), but
before war, chaos and death and such.
 Used Life table and proportional hazards approach.
 Life table cumulative probability without control of any
factors:

31. Daponte continued..
 Fixed covariate model: Female, Urban,
Postsecondary, and maternal age 30-34
protective
 Developed time-varying multivariate analysis
 Two models as follows:

33. Multivariate model

34. Conclusions:
 Mortality:
 Harvard paper of 1991 showed approximately three-four fold
increase in infant/child mortality(92.7 and 128 per 1000births
post war)
 Ali (Lancet) paper showed RR of approx 1.8-2.0 in infant/child
mortality; with weighted death rates of 99 and 118 per
1000births post-war 1991.
 Difference in Pre-war death rates. Likely Harvard study
underestimated death rate due to the high proportion of death
omissions-mostly prewar deaths.
 Mortality continued overall to climb in IRAQ through 1998,
however declining in small section of population (autonomous
group).
 Excess deaths: Likely, closer to 400,000 than 500,000. The
assumption that Mortality would continue to decrease is quite
speculative.

35. Conclusions continued..
 Causality:
 Harvard paper: War is bad for health
 The only smart bomb is a dismantled bomb (duh!!)
 Likely Multiple factors: War, compounded by
Sanctions on an emerging industrialized Society
highly dependent on food/drug/textile imports.
 Sanctions seem to exert independent effect on
mortality.
 Very little on Causality from Ali and others.
Interesting and beneficial to closely compare 2
groups with widely different mortality rates.

36. Banned by Sanctions.
 Items Banned by the Sanctions agricultural pesticides
all electrical equipment
all other building materials ambulances
baby food
badminton rackets
bandages
blankets
boots
cannulas for intravenous drips catheters for babies
children's bicycles
children's clothes
chlorine and other water
purification chemicals
cleaning agents
cobalt sources for X-ray
machines
deodorants
dialysis equipment
disposable surgical gloves
drugs for angina
ECG monitors erasers
glue for textbooks
incubators
leather material for shoes lipsticks
medical gauze
medical journals
medical swabs
medical syringes
medication for epilepsy
nail polish
 nasogastric tubes
notebooks
nylon cloth for filtering flour
other adult clothes
oxygen tents
paper
pencil sharpeners
pencils
ping-pong balls
polyester & acrylic yarn rice rubber tubes
school books school handicraft equipment
shampoo
shirts
shoe laces
shroud material
soap
sanitary towels
specific granite shipments
specific umbilical catheters
steel plate stethoscopes
suction catheters for blockages surgical instruments
textile plant equipment
thread for children's clothes
tissues
toilet paper
tooth brushes
toothpaste
various other foodstuffs
wool felt for thermal insulation
X-ray equipment
X-ray film source: The Scourging of Iraq : Sanctions, Law
and Natural Justice by Geoff Simons, St. Martins Press

37. References..
 1. The effect of the Gulf crisis on the children of Iraq. The
Harvard Study Team. N Engl J Med, 1991. 325(13): p. 977-80.
 2. Ascherio, A., et al., Effect of the Gulf War on infant and
child mortality in Iraq. N Engl J Med, 1992. 327(13): p. 931-6.
 3. Zaidi, S. and M.C. Fawzi, Health of Baghdad's children.
Lancet, 1995. 346(8988): p. 1485.
 4. Ali, M.M. and I.H. Shah, Sanctions and childhood mortality
in Iraq. Lancet, 2000. 355(9218): p. 1851-7.
 5. Blacker, J., G. Jones, and M. Ali, Annual mortality rates
and excess deaths of children under five in Iraq, 1991-98. Popul
Stud (Camb), 2003. 57(2): p. 217-26.
 6. Daponte, B.O. and R. Garfield, The effect of economic
sanctions on the mortality of Iraqi children prior to the 1991
Persian Gulf War. Am J Public Health, 2000. 90(4): p. 546-52.