Friends Journal: The Faces Of Collateral Damage

I am a public health physician. In January I participated in a ten-day emergency mission to Iraq, sponsored by the Brooklyn-based Center for Economic and Social Rights. Our task was to assess the potential consequences to Iraqi civilians of a war on Iraq. As a graduate of the U.S. Air Force Academy and a Vietnam veteran, I have some understanding of the potential consequences of the air war we are about to unleash on Iraq as a prelude to an invasion by U.S. troops. The Pentagon will refer to the innocent victims of this assault as "collateral damage," but I've seen their faces, and I think they should have another name. One that occurs to me is "children," since half the population of Iraq is under 18 years old.

Our delegation was composed of six experts in water, sanitation, emergency health services, public health, and food security. We were given access throughout Iraq to clinics, hospitals, food distribution centers, water and sanitation facilities, and electrical generating plants, as well as granted interviews with Iraqi officials, staff of international agencies, civilians, and diplomatic personnel. We had our own translators.

In many ways, the population of Iraq has been reduced to the status of refugees. Nearly 60 percent of Iraqis, almost 14 million people, depend entirely on a government-provided food ration that, by international standards, represents the minimum for human sustenance. They have a very high infant mortality caused by communicable and waterborne diseases. They experience severe problems with their potable water, sanitation, and electrical infrastructures. The health care system can barely cope with the existing disease burden and there are shortages of medicines. Unemployment is at least 50 percent, and those such as physicians who are employed may only make $8–10 per month. There are limited opportunities for education. There is a pervasive sense of despair and uncertainty regarding the future.

The war has yet to start, but we found the Kerbala Pediatric Hospital that we visited already filled beyond capacity, each bed filled with two or three mothers with their ill children. The pediatrician explained that there were only 28 beds for the 54 patients, so at night many of the mothers would shift onto the floor. Most of the children had the telltale signs of malnutrition—thin skin stretched over protruding bellies, eyes that seemed far too large for their small faces, hair with streaks that Western women often pay for at the hairdresser.

We walked up to a bed where a mother was rocking her tiny, crying three-year-old daughter. The pediatrician said the mother had traveled 200 km because she heard the hospital had a supply of Pentostam, the medicine needed to treat kala azar, or leishmaniasis, as we call it. The pediatrician had not told her yet that there is none. He turned to me and said in English, "It would be kinder to shoot the girl here rather than let her return home to the lingering death that awaits her." Our interpreter, by instinct, translated the doctor's comments into Arabic, and the mother's eyes began to overflow with tears.

Leishmaniasis, we learned from the pediatrician, is reemerging because Iraq is not allowed to import the pesticides that once controlled the sand fly, which transmits the disease. Malaria is also reemerging because mosquito control is no longer possible in parts of Iraq. The incidence of water-borne diseases like typhoid is 1,000 percent of what it was just prior to the Gulf War—2,200 cases in 1990 and more than 27,000 in 2001, according to UNICEF.

After saying good-byes at the Pediatric Hospital, we walked across the highway to the Kerbala water treatment plant. There the woman engineer told us much of the diarrheal disease is caused by poorly treated water, because Iraqis are not allowed to import the spare parts for water treatment plants or the chemicals like chlorine and aluminum sulfate necessary to produce clean water. We saw that only about 8 of the 32 electrical motors that turn the large paddles in the flocculation chambers used for settling solids were still functional; the rest had been cannibalized for parts. There was insufficient chlorine, so the two-step disinfection procedure had been reduced to only a single step.

Later, it was not a surprise when WHO and UNICEF staff explained that 40 percent of water samples in Iraq didn't meet standards for potable water, either for bacteria counts or total dissolved solids. We know what happens when bacteria counts are high. The average Iraqi child has 14 episodes of diarrhea a year now, compared to around three before the Gulf War. That is part of the reason that 70 percent of deaths of Iraqi children result either from diarrheal-related diseases or respiratory infections. The diarrheal diseases weaken their immune systems and make them more susceptible to colds that turn into pneumonias. Malnourished children are more vulnerable to both. The facility's chief engineer said that because the sewage treatment plant in South Baghdad is often inoperable due to lack of maintenance and spare parts, most of the city's wastewater was diverted directly into waterways connected to the Tigris and Euphrates Rivers. We then knew why UNICEF estimates that 500,000 tons of raw sewage are dumped into Iraqi waterways daily. These are the same waterways that are the sources of both potable and industrial water.

What are the consequences of all this? They were rather accurately predicted in a previously classified 1991 Defense Intelligence Agency document that discussed the sanctions imposed on Iraq after it invaded Kuwait. It suggested that if the importation of chemicals were blocked, the already poorly functioning water treatment system in Iraq would soon grind to a halt, disabling most industries that depended upon clean water, specifically mentioning electrical generation, pharmaceuticals, food processing, and petrochemicals. It also predicted that, "Failing to secure supplies will result in a shortage of pure drinking water for much of the population. This could lead to increased incidences, if not epidemics, of such diseases as cholera, hepatitis, and typhoid." This is precisely what has happened. UNICEF estimates that the excess child mortality in Iraq over the past decade has been more than 500,000 children. These children, too, must be counted as "collateral damage" from the Gulf War.

As people watched so-called "smart bombs" zero in on military targets on CNN during the Gulf War, we weren't shown the images of electrical generating plants that were hit on average eight to ten times. Without spare parts these plants have yet to recover fully, and some only operate at 50 percent of capacity causing daily electrical outages for up to 14 hours in some Iraqi cities.

How many civilians will die in the next war? That is difficult to predict with any certainty. Most researchers agree that 10,000 civilians perished in the Gulf War, primarily during the bombing campaign. That figure will surely climb because the U.S. government has threatened that more than 3,000 precision guided munitions will strike Iraq during the first 48 hours of the war. The tactic of a missile exploding every minute during the initial days of a war has been given a name: "shock and awe." The U.S. Department of Defense (DOD) has leaked its war plan to "shock and awe" the Iraqis, specifically striking targets such as the Republican Guards, intelligence and security forces, as well as command and control centers. These are largely located in urban areas where 70 percent of Iraq's 22 million civilians also live.

If the U.S. launches a war against Iraq today, our leaders know that, unlike after the Gulf War, we will not only have to govern the country but will have to rebuild it. For this reason, the DOD would probably refrain from targeting the water, sanitation facilities, and electrical generating plants this time around. (It won't have to, because it can paralyze the electrical grid with wind-dispersed graphite filaments.)

At the same time, the electricity-dependent public health infrastructure such as water treatment, sewage pumping, and sewage treatment plants would come to a halt. Already in Baghdad we stepped gingerly through neighborhoods where sewage was backed up into the streets because an aging pump station failed. What will happen when all pumps fail at once and emergency generators can only supply sufficient power for 10 percent of normal capacity?

Iraq is not like Afghanistan, where people have long ago learned to fend for themselves. Iraq is highly urbanized, and the bulk of its population depends entirely upon a "food basket" provided by the government under the UN-monitored Food for Oil program. The 2,200 calories currently provided per adult are what refugee experts define as the minimum needed for human sustenance. The program, which uses surface transportation for distribution, will be suspended when U.S. forces interdict roads, rails, and bridges to prevent the Iraqi army from movement and re-supply.

Just as there are no spare parts in the country, there is little spare food in cupboards and no spare fat on the bodies of so many children who are already malnourished. Half the population is unemployed, and many families have sold their possessions over the last decade to get by. If war comes, the prospects for avoiding a humanitarian catastrophe are grim. In a country where half the population is under the age of 18, can the U.S. make war on Saddam Hussein and not the children of Iraq?

Iraq once had a modern healthcare system that is now barely functioning. What will happen when the backup generators in hospitals slowly go silent because diesel fuel deliveries stop? What will happen in the operating rooms, dialysis units, and blood banks? Iraqi health professionals answered these questions for us. After a woman physician replied to our many ominous queries in a steady and professional manner, a member of our delegation thanked her and said, "You are very strong." She responded, "We have endured a decade of war with Iran and a decade of sanctions and bombing." And then, losing her composure, she began to cry, adding, "We are neither strong nor brave. We do what we have to do to survive." There is palpable fear in Iraq, and it can be felt everywhere you have a quiet conversation.

The previously mentioned declassified Defense Intelligence Agency document, conversations with UN officials in Iraq, and the experience of several international organizations operating in Iraq reveal there has been a dark side to the enforcement of sanctions. Until last year, every item that was imported into Iraq had to be individually approved by the Sanctions Committee. Made up representatives of some 20 countries, votes were by secret ballot and one negative vote was sufficient to block a request. Recently, a widely used antibiotic that could also be used to treat anthrax was blocked by the Sanctions Committee. Chlorine and aluminum sulfate used in the treatment of water were blocked as "dual use" (capable of both civilian and military use). Stainless steel essential for the screens in wastewater plants has been blocked for years. After enormous pressure was brought to bear by the international community, UN Resolution 1409 was authorized by the Security Council in 2001, providing a list of items that can be imported without going through the months and sometimes years of scrutiny of the Sanctions Committee.

An Austrian physician who read an essay of mine circulating on the Internet, wrote: "Our humanitarian project was blocked by the U.S. objection inside the Sanctions Committee for one year. They considered our medical machines as dual use, although the UN weapons inspectors were involved and they confirmed that not one of our instruments is to be considered as dual use. With our project we are supporting children who suffer from leukemia or cancer."

If the constant litany that visiting delegations in Iraq hear are to be believed, then the sanctions are the root of all evil there today. The truth isn't so black and white—little is, in Iraq. Visitors can see beautiful mosques and gorgeous presidential palaces being built in many places. Ba'athist Party bureaucrats and the military don't suffer the deprivations of ordinary people. Saddam Hussein rules with an iron fist and tolerates no dissent. Statues of him are everywhere and people display posters of him as evidence of their patriotism. The office of one mid-level director in a regional electric department took the prize with seven.

It is almost impossible to know what Iraqis really think because there is a government "minder" present for all visits. In a taxi or on the streets at night, people will ask where we are from and will invariably welcome us when they discover we are from the United States. As much as some Iraqis would like Saddam removed, in private one doesn't sense that they would welcome a U.S.-led war as the means. The Iraqis are a proud people, aware of their place in the history of civilization. Walking through an ornate arch that connects two parts of a market, I was told it was built in 1200 C.E. Several blocks later, I comment upon another building and am told it dates from 3000 B.C.E. Babylon itself is not far outside Baghdad where one of the seven wonders of the ancient world, the "hanging gardens," is now being restored.

The region no longer seems to fear Saddam Hussein. Most believe he has largely been disarmed and his army is no longer a threat. While the New York Times talks about the coalition the U.S. is trying to build, Arab newspapers report on the meeting of the foreign ministers of Iraq's neighbors—Iran, Saudi Arabia, Turkey, Jordan, Syria—to discuss how war can be avoided. These countries all fear the economic consequences of a war. Turkey lost an estimated $25 billion in the Gulf War and has so far refused the $26 billion aid package that the U.S. is dangling in exchange for use of the country as a staging area. They all say that contrary to international law they will not permit the millions of refugees to cross their borders as they did in the Gulf War.

Many think that Osama bin Laden would welcome a U.S. attack on Iraq because nothing could help the cause of al-Qaida more. They fear that television images of Iraqis fighting GIs street-to-street in Baghdad could inflame both the smoldering fundamentalist sentiment as well as the anti-Americanism of ordinary people across the region. We, too, should fear the hatred and resentment that could be unleashed. It could haunt us for decades to come in every corner of the world.

A subject that is infrequently mentioned in the commentaries on this looming war is the impact on economies—local, regional, and global. Our allies largely paid for the Gulf War. Without such friends this time around, the U.S. administration's legal team has determined we can charge the Iraqis using their oil revenues to finance the war against them. If Saddam torches his oil fields as he has promised to do (and did in Kuwait), then it could take even longer than the estimated five years to rehabilitate them. A Saudi oil official has said that if that happens, oil prices could rise to $100 per barrel. The last time that happened, it caused a global recession, from which Africa needed a decade to recover. The U.S. economy is not in a strong position to withstand a war, yet there is surprisingly little debate in the U.S. about the possible economic consequences.

Even now, Iraqi oil fields have had no spare parts for a decade and are operating at less than 50 percent of pre-Gulf War capacity. Already, the Food for Oil program is billions of dollars behind in critically needed items that have been authorized but not yet supplied such as food, medicine, spare parts for water treatment plants, and electrical generators. Almost half the proceeds are used for war reparations to Kuwait and to administer the program; the other half keeps Iraq alive. The U.S. has budgeted nothing for this war, and if it expects to pay for it out of Iraqi oil revenues, it will have to further starve Iraqis to do so.

This scenario is conservative. I have not taken into account any use of weapons of mass destruction, or the possibility that the war will set loose massive civil disorder and bloodshed, as various groups within the country battle for power or revenge. I have also ignored what would happen if U.S. Forces became bogged down in house-to-house fighting in Baghdad, which could easily become another Mogadishu or Jenin.

There was a lot that made me angry on this trip. I have worked in war zones before, and I have been with civilians as they were bombed by U.S.-supplied aircraft. I don't think I've experienced anything on the magnitude of the catastrophe that awaits our attack on Iraq.

On Saturday, February 15, in cities around the world, millions of people joined their voices and prayers in hopes of stopping this war. The demonstrators urged agreement with the majority of the UN Security Council that believes that the weapons inspectors are making progress and must be allowed to continue their mandate to search for and disable Iraq's weapons of mass destruction. There is widespread acknowledgment that Saddam Hussein has dragged his feet on disarming, but there is also a strong desire for the international community to fulfill its obligations under Chapter 7, Articles 41 and 42 of the United Nations Charter—to exhaust all peaceful avenues before resorting to force.

If the U.S. pursues this war without the backing of the UN Security Council, it will undermine a half century of efforts to establish a community of civilized nations where there is the rule of law. We must search for alternatives other than war to resolve these troubling issues. We must be creative in developing sanctions that don't harm the most vulnerable sectors of society—pregnant women, children, and the elderly.

I am troubled by what I have seen in Iraq. I am inspired by the millions who recently made their voices and prayers heard around the globe. I am comforted by words sent by a friend, based on the Talmud: "Do not be daunted by the enormity of the world's grief. Do justly, now. Love mercy, now. Walk humbly, now. You are not obligated to complete the work, but neither are you free to abandon it."

- AUTHOR NOTE: Charlie Clements attends Santa Fe (N. Mex.) Meeting. In 1984 American Friends Service Committee made a film about his work in El Salvador called Witness to War, which won the Academy Award for Best Documentary Short. He is currently CEO and president of WaterWorks, a not-for-profit organization that assists communities in the southwestern United States that are without potable water and wastewater systems. He also teaches at the Bartos Institute for the Constructive Engagement of Conflict at the United World College in Montezuma, New Mexico. He is a former president of Physicians for Human Rights and served on their board for 15 years. He is a Distinguished Graduate of the U.S. Air Force Academy and a Distinguished Alumnus of University of Washington School of Public Health. For the executive summary and final report of the mission described in this article, see http://www.cesr.org.

Photos from top: Jason Florio http://www.floriophoto.com; Jason Florio; Robert Jean Huber; Terry J. Allen mailto:tallen@igc.org.

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