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400,000- 500,000 children and infants executed due to Iraq sanctions and Gulf war....For those that refute this claim and the damaging effects of Sanctions and "Selective," smart-bombing on select populations, please feel free to review the BEST evidence in a presentation I gave 10 years ago....Happy mother's day.

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  1. 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. 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. 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. 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. 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. 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. 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. 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. 9. Ascherio et al.
  10. 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. 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. 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.
  13. 13. 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.
  14. 14. 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
  15. 15. 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.
  16. 16. 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
  17. 17. 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
  18. 18. 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.
  19. 19. 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}
  20. 20. 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.
  21. 21. 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.
  22. 22. 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
  23. 23. 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.”
  24. 24. 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:
  25. 25. Daponte continued..  Fixed covariate model: Female, Urban, Postsecondary, and maternal age 30-34 protective  Developed time-varying multivariate analysis  Two models as follows:
  26. 26. Multivariate model
  27. 27. 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.
  28. 28. 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.
  29. 29. 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
  30. 30. 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.