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NEWS: Owen Dyer Poor security is biggest impediment to health care in Iraq BMJ 2003; 326: 1107-b [Full text]

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Who can break the wall of insecurity in Iraq ?

Masamine Jimba, Susumu Wakai   (29 May 2003)

Waterborne Disease in Iraq

Bill Kirkup   (8 June 2003)

Who can break the wall of insecurity in Iraq ? 29 May 2003
Masamine Jimba, Assistant Professor University of Tokyo, Japan 113-0033, Susumu Wakai Send response to journal: Re: Who can break the wall of insecurity in Iraq ?	Owen DyerÕs timely article addressed the importance of security for improving health care in Iraq (1). As Connolly and Heymann stated, Ôconflict promotes factors that lead to increased incidence of infectious diseaseÕ and Ôthe collapse of public health infrastructure and the lack of health services hampers control programmesÕ (2). As a result, conflict-related infectious diseases has sometimes killed more people than battle wounds; thus they became known as the Ôthird armyÕ (2). This history seems destined to repeat itself as Iraq faces cholera. Security is indeed important, not only to avoid murder of health workers or to allow aid agencies to work, but also to allow local Iraqi health workers to save the lives of their own people. In 1994, we observed a successful cholera control effort in the Gaza Strip. Although there were approximately 600 suspected and 93 confirmed cases of cholera, there was only one death (3). This success during the post-conflict period built the confidence of Palestinian health workers in their ability to run their health service system by themselves. After a period of upheaval, this kind of confidence is indeed a reward for health workers. Like Palestinians, Iraqi health workers have sufficient skills to control cholera, if only security is assured. For many Iraqi health workers, insecurity is therefore like a transparent wall. Through the wall, they can see their own people suffering and dying from disease, while knowing that they could save them if only the wall, or insecurity, is broken. Military involvement in such a crisis is controversial (4). However, if the military is not the answer, who else can break the wall of insecurity, and how? What does history teach us about this? If no such history exists, canÕt we create a fourth army for a new start of Iraq? 1) Dyer O. Poor security is biggest impediment to health care in Iraq. BMJ 2003; 326: 1107. 2) Connolly MA, Heymann DL. Deadly comrades: war and infectious diseases. Lancet 2002; 360 Suppl:s23-4. 3) Jimba M. Community health activities in the Gaza Strip: cholera and health promotion. Hokenfu-zasshi 1995; 51: 880- 884. 4) Terry F. Military involvement in refugee crises: a positive evolution ? Lancet 2001;357:1431-32. Competing interests:   None declared
Waterborne Disease in Iraq 8 June 2003
Bill Kirkup, Public Health Adviser, Coalition Provisional Authority Baghdad Send response to journal: Re: Waterborne Disease in Iraq	It seems that the incidence of all types of diarrhoea is about twice the levels expected in Iraq. However, definite evidence is hard to obtain, not only because of damage and looting to public health laboratories, but also the breakdown of surveillance systems and communications. The reasons for the increase, which certainly includes cases of cholera, are failures of water treatment plants, damaged water pipes, and blocked sewers leading to raw sewage pooling around leaky water pipes and entering the Tigris and Euphrates in large quantities. These problems, much more the result of damage after the war and neglect before it than the war itself, will take time to rectify. In the meantime, the Iraqi Ministry of Health is working hard and well to counter the dangers, in conjunction with the Coalition Provisional Authority, International Organisations and Aid Agencies. Damaged pumping equipment has been replaced or repaired. We have been able to increase supplies of chlorine gas significantly, to avoid the risk of local shortages. As a result, we are able to recommend increasing the level of chlorination at the treatment plants to offset the saturation of added chlorine by the quantities of organic contaminants that are present in some water. We have arranged the supply of large quantities of hypochlorite tablets and safe water containers for domestic chlorination in areas where populations will still be getting unsafe water (boiling is not an option for most families as fuel is in short supply). A public information campaign is being mounted to inform people about the need for safe water, how they can access these supplies, and how to use oral rehydration salts to avoid dehydration. The incidence of both watery diarrhoea and bloody diarrhoea now appears to have reached a plateau, but it is far to early to be complacent, and there will surely be more cases. The measures that have made this possible depend on the valuable work of a range of agencies of all types. The important point, however, is that the measures are taking place through the direction and management of the Iraqi Ministry of Health and its Preventive Medicine team, and are being achieved by the efforts of the majority of Iraqi people. This is as it should be. It would be a great pity if their efforts continued to be jeopardised by the very real security problems caused by the actions of the minority. Competing interests:   I am currently seconded as public health adviser to the Coalition Provisional Authority, Baghdad