Since August 2011, we’ve publicly speculated about a backlog of 30,000 Iraqi children in need of lifesaving heart surgery. After decades of war and sanctions, in a country that lacks a national registry for heart defects, have you ever wondered where The Backlog numbers come from? Here’s a peek behind the curtain…
UNICEF states the approximate number of children born in Iraq in 2010 was 1,125,000i. Numerous studiesii estimate the normal rate of children born with congenital heart defects (CHD) to be somewhere between 6-10 out of every 1,000 children. As a percentage, that is somewhere between 0.6% and 1% “incidence.”
That means that every year in Iraq, between 6,750 and 11,250 children are born with congenital heart defects.
However, there are other factors that potentially raise the incidence of CHD in Iraq beyond 1%. Some of these factors include increased rates of diabetes, vitamin deficienciesiii, intrafamily marriageiv, and environmental exposuresv. It’s difficult to know exactly how much all of this combined would raise the incidence of CHD in Iraq. But we can confidently assume that at least 11,000 children are born with heart defects every year in Iraq, based on the incidence and amount of children born.
Thankfully, not every child born with CHD will have severe enough defects to require surgery. But somewhere between 25-50% of those 11,000 children will need surgery or else they will dievi. Sadly, the healthcare infrastructure in Iraq was decimated by sanctions, war, and internal strife and no longer has the ability to reduce its backlog or operate on new children born with CHD. Every year, 90% of the children in Iraq fail to receive the surgeries they require to survive.vii
Each new year, up to 5,500 new children will need surgery. This is what we call The Backlog. Unfortunately, some 31% of all children born with CHD will die in the first year without surgery; they would not make it to the next year’s backlog. Similarly, many infants die from other causes, so that would also lower the amount of children on the backlog. Amazingly, some children heal on their own.
When children come off the backlog from these, or any other, causes it’s called attrition. While it’s hard to measure the rate of attrition, it’s almost insignificant if we assume an incidence rate higher than 1%. If we simply began (albeit arbitrarily) with the beginning of the Iraq War in 2003, our estimates above would place The Backlog between 22,000 and 44,000 kids. That averages to around 33,000 children who need surgeries to survive.viii
This is why we work so hard each day to train Iraqi doctors and nurses across the country—it is only by establishing local heart care centers that these children will be served as they are born and the future buildup of The Backlog will be avoided!
v Jenkins KJ, Correa A, Feinstein JA, Botto L, Britt AE, Daniels SR, et al. Noninherited risk factors and congenital cardiovascular defects: Current knowledge. Circulation. 2007 June 12;115(23):2995-3014.
vii Based on PLC surveys conducted with government officials, cardiologists and surgeons across Iraq.
viii The actual number may be less due to our inability to calculate real attrition and our inability (as yet) to estimate the actual increased incidence due to extraordinary factors in Iraq. We do not want to engage in hyperbole or sensationalism. But we choose the higher side of the spectrum because our mandate requires us to help the Ministry of Health establish a sufficient number of surgery centers across the country. Choosing the high number will not cause us to develop too many centers, but choosing the lower end of the spectrum might very well cause us to develop too few.
Whenever someone hears about our kids or reads about our work they almost always arrive at the same question: “How did Iraq get this way?” “What caused this?” “Who’s to blame?”
Well, after 4 years of working throughout this country we believe we can provide you with a concise answer to that incredibly complex question. This isn’t about guilting anyone or pointing the finger (there’s already too much of that going around), but it is a hard look at the answer to your question.
Based on Iraq’s history, here are 5 ways to destroy a nation’s healthcare system:
1. Limit a country’s ability to operate politically and economically
In 1990 the UN Security Council passed Resolution 661, which imposed broad, restrictive regulations upon Iraq. In a nutshell, these regulations stipulated that no country in the UN could import or receive any goods from the country.
Unfortunately, the sanctions did more than impede the political and military action of the Iraqi aggressors. The Iraqi economy, that had been so dependent upon oil exports and foreign trade, crashed as a direct result of the Resolution 661.
In 1989 Iraq’s gross domestic profit was over $66 billion. Just seven years later it was estimated as being $10.8 billion. In 1989, annual income per household was $3,510, and by 1996 had fallen to less than $500. Before the sanctions, 93% of the population had ready access to healthcare institutions, which were staffed primarily by physicians who had been trained in Europe or the United States.
This economic collapse primed the country for the health crisis it is in today, a health crisis that has lead to the death of inestimable millions over the last two decades.
2. Slash governmental healthcare funding
In the 1990′s Saddam Hussein cut spending on healthcare by 90%. Continued education, supplies of necessary equipment, and valuable public health programs all suffered without adequate funding research.
Without funding and governmental support, the healthcare system deteriorated.
3. Reduce the number of medical professionals in the country
In some areas, insurgents made it a practice of targeting medical professionals. Although many doctors were not individually targeted, they were still in danger. Ambulances were frequently robbed of their medical supplies, and it was not uncommon for gunmen to enter hospitals and force doctors to care for their injured family members or comrades.
Another blow was dealt to the stability of Iraq’s healthcare when many doctors and nurses, who were lucky enough to escape death, fled the country in a mass exodus, further damaging the quality of the Iraqi healthcare system.
The murder and exodus of Iraqi healthcare professionals is tragic. It has left many families broken and many patients without the care that they need. But the negative effects extend beyond their families and the patients they left behind. Without their mentor-ship, expertise, and knowledge, generations of students from universities and teaching hospitals will continue to have insubstantial educations.
4. Destroy physical healthcare infrastructure
In 2003 American and Coalition forces destroyed two primary public health laboratories and an estimated 12% of hospitals. While speaking about the state of the nation’s healthcare infrastructure, former Minister of Health of Iraq, Khudair Abbas, explained that of the remaining primary care centers, “15% have been looted. Even though 80% remain intact, 40% need extensive repairs…13% do not have clean water and one third are staffed primarily by paramedics rather than physicians”.
During the Gulf War, American and coalition forces destroyed key elements of Iraq’s infrastructure. “Bridges, communications, electricity supplies, water and sewage systems, weapons factories, healthcare facilities, administrative centers, warehouses” and homes were destroyed. While this may have been a strategy aimed at ceasing Iraq’s ability to make war, this strategy did far more than defeat the Iraqi military.
5. Overburden the healthcare system by creating too many patients
The above contributing factors deal primarily with political, structural, organizational, or educational deficits. Ultimately, however, it is the population of patients that compose the largest component of any healthcare system. And, regrettably, there is a vast population of patients in Iraq.
The demolition of water and sewage treatment plants lead to outbreaks of typhoid and cholera. In 1989, there were no cases of cholera per 100,000 people; just 5 years later there were 1,344 cases per 100,000 people.
According to studies, by 1996 31% of children under five were chronically malnourished. Just a year later, there were a million children under the age of five who were malnourished, and a year after that 70% of women were suffering from anemia. Another study, consistent with the information on malnutrition, found widespread, chronic stunting in school children as an indication of long-term malnutrition.
Poverty’s wide-spread negatively affects the livelihood of the Iraqi people. Low socioeconomic status is associated with lower levels of education, poorer nutritional intake, and higher risk of congenital heart defects.
Research shows that poor diet contributes to far more negative effects than weight loss, anemia, nutritional deficiency, and compromised immune system. Without the funds to afford healthier food, mothers with higher intake of saturated fats and lower intake of nicotinamide (vitamin B3) have increased risk of giving birth to children with congenital heart defects. 5, 8 Furthermore, low dietary intake levels of folic acid (vitamin B9) around the time of conception have been linked to higher risk of neural tube disorders.
But nutrition and education are not the sole arbiters of death and ill health. Many parts of the country still suffer from the chemical and biological attacks perpetrated by Saddam Hussein. Not only are individuals suffering from primary exposure, but research supports that children of those who were exposed suffer secondary effects in the form of birth defects.
The list of health problems and their contributing factors continues ad nauseam, and the patient-load continues to overwhelm doctors.
The evidence shows that the state of Iraq’s healthcare system has been nearly two decades in the making. The downward spiral began with sanctions in the 1990’s by making the nation more susceptible to economic collapse. It continued with a multitude of factors including military action by the US and Coalition forces, violence wrought by religious extremists, and a vast backlog of patients.
The question remains, is it too late for Iraqis to rebuild their healthcare system?
Is Iraq too far gone?
Of course not! The restoration of Iraq’s medical infrastructure is happening now!
This November 5th will be our biggest surgical mission yet–lives will be saved, doctors will be trained and Iraq will be one big step closer to restoring what was broken!