Sanctions, Saddam and Silence: Child Malnutrition and Mortality in Iraq

By Mary C. Smith Fawzi and Sarah Ziadi

We visited Iraq in 1991, after the Gulf war. Recently, we had the opportunity to return to Iraq as participants in a U.N. mission sponsored by the Food and Agriculture Organization (FAO). Our goal was to assess the nutritional status and mortality of children under the age of five. To do this, we conducted a community-based survey throughout the city of Baghdad. The situation in the country had significantly deteriorated since our 1991 visit. Street children, a rare sight in 1991, were common now. Parents with severely malnourished children were begging on the streets. During the past five years, prices of basic food items had risen dramatically. The price of wheat flour had increased by 33 times since 1993 and over 11,000 times since July of 1990, prior to the institution of economic sanctions by the U.N. Security Council. All sectors of society, aside from Saddam Hussain's inner circle, have been affected.

While conducting the community survey in a middle-income part of the city, we had the opportunity to meet Um Fatima, who has four children and whose husband is a civil engineer. Under the current economic situation his salary of 5,000 Iraqi dinars (ID) per month is not enough to meet the basic needs of his family. With a month's salary he can purchase a little more than 2 pounds of chicken or 1 pound of red meat. One egg costs ID 130 and milk for children is a luxury. Shoes for his two sons cost him one-and-a-half month's salary. Pencils, pens and notebooks for school also are very expensive to buy. The family relies on the government food ration, which meets one-third of their caloric needs. The ration consists of flour, rice, sugar, oil and infant formula for families with a child under one year of age, but is lacking in protein, minerals, and essential vitamins. Um Fatima's youngest child, Mustafa, was severely malnourished and I could feel his ribs when I lifted him to be measured.

Children under the age of five are the most vulnerable.

One might ask, "If people are struggling in the middle class neighborhoods, how are the poor people surviving?" The reality is that many are not. According to the results from our community-based survey, there has been nearly a five-fold increase in mortality among children under the age of five in Baghdad compared to the period prior to the imposition of economic sanctions. The sustained mortality has resulted in half a million child deaths related to the war and the sanctions occurring over the past five years.

On a walk through Saddam City, one of the poorest neighborhoods of Baghdad, I saw obvious examples of severe malnutrition. There were classic cases of marasmus, severely wasting children who are just "skin and bones."

One woman, Mouna, the mother of a severely malnourished child, pointed to the bread provided by the government food ration. "I've been trying to give my two-year-old son this bread, but he cannot eat it," she said. "Now he is wasting away. I just don't know what to do." The bread was heavy and dense, containing not only wheat and barley but also non-grain material such as stones, straw, and remains of insects and pests.

It is expensive to purchase bread on the open market, however, because one kilogram of wheat flour costs one-third of the average monthly salary. As a result of such skyrocketing prices of basic food items since the beginning of the economic sanctions, the rate of malnutrition among children under the age of five in Baghdad has increased over four-fold since 1991. This dramatic increase in malnutrition also is caused by unsanitary environmental conditions, such as open sewage in the streets. In Saddam City, a woman invited me into her home exclaiming "Look, look at the condition of my home." Her entire living room was flooded with fecal matter floating in green sewage water. Sanitation systems cannot be maintained because of an inability to obtain spare parts as a result of the sanctions.

Malnutrition often results in death among children under the age of five, who are the most vulnerable group. One gentleman we interviewed described how his two young daughters, Sarah and Amina, died from anemia, which is caused by iron deficiency. Iron deficiency can be caused by a lack of consumption of red meat or green leafy vegetables. However, it also can be caused by parasitic infections resulting from unclean drinking water. Since the institution of economic sanctions, basic items to create safe drinking water, such as chlorine, cannot be obtained.

The Iraqi government has described a dramatic increase in mortality and malnutrition as a result of the sanctions. However, our international research team wanted to obtain objective information on the status of children under the age of five. We randomly selected 25 neighborhoods based on the population size of each city district. Within each neighborhood we interviewed women between 15 and 49 years old in 24 households who had had a live birth within the past 10 years. We obtained information on 693 households, 768 mothers, and over 2,000 children under 10 years of age. For nutritional status, 594 children under five years of age were weighed and measured.

For mortality, registration cards were obtained for 74 percent of the children for documenting date of birth. The interviewers were from the Nutrition Research Institute in Baghdad and comprised three teams led by supervisors from international organizations, including UNICEF (Baghdad office), the Center for Economic and Social Rights in New York, and Harvard University. The team supervisors performed almost all of the measurements of weight and height used in the estimation of malnutrition rates.

Severe Wasting

The descriptions of their suffering obtained from mothers in Baghdad are supported by the empirical data we obtained. The four-fold increase in malnutrition, or wasting, among children under the age of five is startling. In 1991, the estimate of wasting in Baghdad was approximately 3 percent, similar to that in Kuwait prior to the Iraqi invasion. However, today the percentage of children who are "wasted," experiencing severe malnutrition that is directly visible in their ribs and limbs, has reached 12 percent. This is comparable with lesser developed countries such as Madagascar and Myanmar. Severe wasting is not limited to the poor areas of Baghdad, however. Thirteen percent of children whose mothers completed their education at the post-secondary school level were wasted in our survey.

These results are appalling if one considers the fact that Iraq is 70 percent urban and a middle-income country. Typically, a higher level of wasting occurs in countries that are predominantly rural, where access to sanitation and adequate health services is severely lacking. The level of stunting, children short in stature for a given age, also has risen dramatically.

In 1991, the rate of stunting in Baghdad was similar to what has been observed in Kuwait. However, in Iraq since the dramatic increase in prices of basic food items, the level of stunting, 28 percent, has reached a rate comparable to that observed in the Congo. These results indicate that an entire generation of Iraqi children has been significantly affected. Given the known relationship between malnutrition and mental capability, their potential for developing a democratic system for the future of Iraq is greatly diminished.

The dramatic increase in severe malnutrition corresponds with our mortality results, which reflect nearly a five-fold increase in child mortality. Infant mortality has increased two-fold compared with the time period prior to the economic sanctions. In fact, a two-fold increase in infant mortality was observed after the Gulf war and has persisted over time until the present.

During that war, Iraq's infrastructure was targeted, including the electrical infrastructure which provided power for the maintenance of Baghdad's sanitation system. As a result, diarrheal disease-related deaths increased after the Gulf war because, under economic sanctions, Iraq cannot obtain the spare parts needed to repair the sanitation system.

At this level of malnutrition and excess mortality among children under the age of five, Iraq is increasingly becoming like a concentration camp. The economic pressure exerted on the country by the U.S. and the international community effectively serves as the barbed wire.

Only those individuals with extensive personal assets, perhaps less than one percent of the population, can leave the country. Only members of Saddam Hussain's entourage remain unaffected by the sanctions. Children, who are the most vulnerable and least powerful, have been hit the hardest.

As members of the international community, we are responsible for the suffering of Iraqi children. Our continued silence results in genocide.

The authors would like to acknowledge the support of other team members including Dr. Peter Pellett, Dr. Muhammad Manzoor Khan, and Dr. Q.K. Ahmad, as well as the efforts of the Nutrition Research Institute.

Dr. Mary C. Smith Fawzi is a research fellow at the Harvard School of Public Health in Boston, MA. Dr. Sarah Zaidi is the science director at the Center for Economic and Social Rights in New York.