An FAO Mission visited Iraq from 25 July to 1 September, 1995 with the task of investigating the nutritional status of the population and assessing the crop and food availability situation which prevails after the imposition of an embargo in 1990. The Mission received full cooperation from the staff of UN agencies (UNICEF, UNDP, WFP, WHO) based in Baghdad and elsewhere in the country and from the government agencies and NGOs involved in food and nutrition activities. The Mission travelled extensively in various parts of the country including the Northern Governorates, visited health, agricultural and food distribution facilities, interviewed farmers and concerned professionals and carried out independent market surveys for a cross sectional assessment of food availability and market prices. With the cooperation of the Nutrition Research Institute of the Ministry of Health, the Mission conducted a survey in Baghdad to assess the nutritional status and mortality of children under-five years of age. The Mission also reviewed existing and available data on food production and availability and nutrition and health status obtained from a wide range of governmental, UN and NGO sources.
The estimated total population of Iraq is 20.7 million with 42% being aged less than 14 years. The population is mainly urban (71 %) and has an annual growth rate of 2.7%. Adult literacy is high (95%) and there are 22 Universities and Institutes of Higher Education. Until 1990 there were very significant advances in the provision of health care and major construction projects gave the country a first class range of medical facilities both in large towns and through a series of clinics in rural areas. As a result of these improvements infant mortality rate (IMR) had declined to a value of about 40 per 1000 live births by the late 1980s.
The Iraqi economy was dominated by the oil sector from the early 1950s
until the major cessation of exports in 1990. During this period there was
improving prosperity for the vast majority of the population. With the
embargo on oil exports (except for limited sales to Jordan) economic
decline has proceeded rapidly over the last several years and is reflected
by the exchange rate of the US$ which currently (August 1995) is in the
order of 1 US$ = 2,000 Iraqi dinars (ID). This decline has precipitated
severe problems throughout the whole country which were described by
earlier missions in 1993 as demonstrating pre-famine conditions. The
agricultural sector has been given high priority by the government to
ensure food security through greater self-sufficiency. However, there
continues to be a high dependence on imported foods which is increasing.
Following the Gulf war, the country is now divided into two regions: the
Government of Iraq (GOI) consisting of 15 governorates and the North
composed of the Governorates of Erbil, Dohuk and Suleimaniya.
Crop Production and Food Availability
Cereal production for 1994/95 has been estimated at 2.5 million tons, about 10 per cent lower than last year and about 16 per cent lower than the average harvest of the previous 5 years. Moreover, the consumable output of wheat, which accounts for about half of the cereal output, is further reduced by the presence of high levels of non-grain impurities. To reflect this the conversion ratio of wheat into flour has been re- duced to 80%.
It was earlier forecast that the cereal output in 1994/95 would increase relative to the previous year; but, in spite of good performance of the rainfall and efforts of the government and international organizations, severe constraints relating to agricultural machinery, particularly nonavailability of essential replacements and spare parts, good seeds, fertilizers, pesticides, and herbicides has resulted in a decline in output. Livestock, poultry and fish subsectors also suffer from severe setbacks because of shortages of machinery, equipment, spare parts and essential drugs.
The shortages of basic foods are enormous. Rough calculations show that an amount of US $ 2.7 billion would be necessary to import basic foods to meet the shortages anticipated for 1995/96. In view of such food shortages, there is a renewed emphasis on the production of vege- tables and fruits to supplement other food items. The production of vegetables, however, remains rather limited. The output of dates is about the same as last year but better than the average of the last few years. Very little is now exported and dates are widely used as a supplementary food.
Prices of basic food stuffs have risen phenomenally. For example, the price of wheat flour in August 1995 is 11,667 times higher than in July 1990 and 33 times higher than in June 1993. The increases are in the order of 4,000 - 5,000 times in the case of several other items compared to July 1990 and 30 to 60 times compared to June 1993. On the other hand, household incomes have virtually collapsed for a large majority of the people (about 70 per cent). The average civil service emoluments are ID 5,000/month and unskilled workers rarely find work. Many have been selling household and personal effects to buy food. People in collective villages in the north were seen selling bricks and other material by pulling down their own houses. Thus, the people have been squeezed into a precarious position by a combination of hyper- inflation and collapse of household incomes. As a consequence the number of beggars and street children have increased enormously.
WFP assistance has also been constrained by a lack of donor response, resulting in a reduction in its food assistance to vulnerable groups, both in terms of quantities supplied and the number of people served. Only if donors adequately respond can WFP provide food assistance to the targeted groups. Due to lack of supplies, WFP could not provide any food assistance in south and central Iraq during June-August 1995 and in the north during August. People in institutions and hospitals are given priority and now being served the allocated amount.
The situation of famine has been prevented largely by an efficient pu- blic rationing system which provides a minimum food basket to all Iraqi families excluding the northern region. The food basket which earlier provided 53 per cent of the 1987-89 food energy availability was re- duced from September 1994 and now provides 34 per cent. The reduction is due both to decreasing grain availability as well as the increasing cost burden it imposes on the government in Iraqi dinars and in foreign exchange. The estimated resources to maintain rations in 1995/96 at the present level are ID 269.5 billion plus US$ 258.1 million. Given these difficulties, the whole system is unsustainable and its collapse will have disastrous consequences for a significant majority of Iraqi people. Nutrition and Health
As noted above, catastrophe in the Republic of Iraq has been avoided by the widespread availability of the Government food ration. This, however, provides only about one-third of the food energy and protein availability when compared to 1987/89. The ration, moreover, is deficient in a number of minerals and vitamins especially iron and vitamins A and C. Animal protein is also lacking, and hence such a cereal based diet is deficient in Iysine. All additional nutritional needs must be provided at market prices which are beyond the means of most families. For children less than 1 year of age the monthly ration (1,800 g baby milk) provides about one-half of needs for food energy and protein and a somewhat higher proportion of minerals and vitamins because of the fortification present in such products.
Since 1993 the situation has become much worse for the majority of the population, with malnutrition, including under-nutrition and micro- nutrient deficiencies, commonly seen both in hospitals and in the ge- neral population. Both marasmus and kwashiorkor were widely observed in paediatric wards throughout the country and presented many of the classically recognized signs such as pedal oedema for kwashiorkor and severe wasting, especially visible in the ribs and limbs together with "old man faces" for marasmus. The monthly average number of cases of kwashiorkor and marasmus has increased 50 fold since 1989 while the monthly average number of deaths (denominators unspecified) for children under five years has increased nearly 8 fold. These data were provided by the GOI and were unable to be confirmed by the Mission. In view, however, of the malnutrition observed, the health hazards in the water supply, the degree of inflation throughout the period and hence the inability of many to purchase food together with the decline in the overall health care system, these data are plausible.
Vitamin A deficiency showing Bitot's spots and xerophthalmia was reported from a number of centres. The frequency of observation remains low but any evidence of clinical vitamin A deficiency must be taken seriously. An increasing prevalence of iron deficiency anaemia was observed in both children and pregnant women. Increased availability of iron supplementation programs is recommended. In the present circumstances flour fortification with iron as well as other micronutrients such as calcium, thiamine, niacin and lysine, while desirable is impractical given the limited resources and deteriorating infrastructure. Distribution of anti-helminthic drugs would potentially reduce the burden of anaemia in the population.
While food is readily available in markets the purchasing power of the average Iraqi has declined, especially for the salaried civil servants and pensioners. The Ministry of Health estimates that 109,720 persons have died annually between August 1990 and March 1994 as a direct result of sanctions. The Mission had no way of confirming this figure. Famine has been avoided by the widespread availability of the Government food ration. This Government ration is not available in the northern region and all food there must be purchased on the open market. For this and for a number of additional reasons which include factional fighting, the decline in external assistance, high prices and many previous government employees not receiving salaries, child malnutrition is also widespread in the North.
The water and sanitation system remains critical throughout the country with the Basrah area (1 million population) being the most serious. The basic reason is the lack of spare parts for a variety of equipment throughout the system which cannot be purchased without foreign exchange. In addition, specific Sanctions Committee approval is also required for most of the items. Overall the situation concerning sewage disposal in Basrah has deteriorated even further since 1993 when it was last seen and described as serious. Within the city there were huge areas of sewage water, sometimes green with algae and sometimes showing visible faecal material. These areas were grossly unhygienic and much of the city smelled badly as a result of these overflows. This of course produces severe hazards to health which can seriously influence nutritional status in children. Under these circumstances it was not surprising that there were many cases of infectious diseases including typhoid fever and infective hepatitis in the hospitals as well as widespread gastroenteritis in the hot summer months and in consequence many cases of nutritional marasmus. What remains surprising, however, is that the city has been able to avoid major epidemics in the presence of these very bad sanitary conditions.
In contrast to the general deterioration in sewage disposal, water availability may have marginally improved with the very large number of strategically sited water tanks throughout the city where drinking water is sold. Despite the slight increase in availability of potable water, the quality for the piped water supply remains poor with 65 % of samples failing either microbiological or mineral purity tests. While these descriptions are for Basrah, similar problems exist in many towns and cities throughout the country including Baghdad.
The hazards of water supply and sewage disposal are thus nationwide and the effects on health are serious. As an example government statistical office figures show 1819 cases of typhoid fever in 1989; this had risen to 24,436 cases in 1994. Similarly there were no reported cases of cholera in 1989 but 1,345 cases were recorded in 1994. The interaction between nutrition and infection is such that poor water quality and sanitation are contributory causes to both growth failure and acute malnutrition requiring hospitalization in children. The lack of capital for repair and updating of the water supply and sewage system is a significant factor associated with both malnutrition and excess infant mortality. The parallel problems of waterlogging and salinity of agricultural land with consequent reduction in the area available for food production should be noted. The causes relating to lack of spare parts for pumps and equipment are identical.
The food industry was returned to the private sector in 1990 but despite this, total production is only a fraction of the earlier level. This is due to a variety of causes including non availability of both raw and packaging materials as well as restrictions on the use of sugar in manu- facturing. It has generally been more profitable to import products from the cheapest sources which are often past their expiration dates or declared unfit for human consumption. One of the few growth areas in production is date syrup which, because of the non-availability of sugar for sweets, is sold widely as a substitute for jams and preserves. Additional problems for food production from small manufacturers in the private sector lie in poor quality control and the use of non-food grade materials for food use. The latter can include emulsifiers, thickeners, dyes and other chemicals. Regulations are unable to be enforced and very real food safety hazards exist. Adequate mechanisms for food safety need to be re-established although it is recognised that these will have low priority in relation to the paramount needs of supplying food enerqy to the population.
The 1995 Baghdad nutrition and mortality survey of children under-five years of age, conducted between August 23 to 28, was a collaborative effort between the FAO Mission and the Nutrition Research Institute (NRI), part of the Ministry of Health. Six hundred and ninety-three households were visited and 768 mothers were interviewed. Information was collected on 2120 children under 10 years of age, and a total of 594 children under-five years of age were measured for anthropometry. Percentiles and Z-scores for height-for-age, weight-for-age and weight- for-height were calculated using EPI-Info, version 6. Malnutrition was defined as the percentage of children less than -2 standard deviations (SD) below the median values for the NCHS (United States National Centre for Health Statistics) standardized distributions for the indicators: stunted (height-for-age), underweight (weight-for-age) and wasted (weight-for-height).
The percentage of children below -2 SD in urban Baghdad was 28% for stunting, 29% for underweight and 12% for wasting. Severe malnutrition, defined as the percentage of children below -3 SD, was noted among children: 10% for stunting, 7% for underweight and 3% for wasting. Mild malnutrition, defined as the percentage of children below -1 SD, was: 56% for height-for-age, 65% for weight-for-age and 39% for weight-for- height. The level of wasting was highest among children 1-3 years of age with a second peak occurring at age 4 to 5 years. In addition, a high prevalence of wasting was noted among children with illiterate mothers (16%) as well as those with secondary (14%) and post-secondary level of education (13%).
The deteriorating nutritional status of children is reflective of events which are occurring in Iraqi society - lack of purchasing power and high prices for basic food items, poor water and sanitation quality, and high burden of infectious and parasitic diseases. Since 1991, shortly after the inception of the sanctions, the nutritional status of children in Baghdad has significantly deteriorated. Compared with 1991 estimates, the current survey demonstrates a 4-fold increase in wasting for the city of Baghdad. Prevalence estimates for stunting and underweight have also risen dramatically. The deterioration in nutritional status of children is reflected in the significant increase of child mortality which has risen nearly fivefold since 1990.
For Baghdad, a highly advanced urban society, the prevalence of underweight children (29%) has increased to a level comparable with children from Ghana (27%) and Mali (31%). For stunting, prevalence rates are similar to estimates from Sri Lanka (28%) and the Congo (27%). Furthermore, the prevalence of wasting in Baghdad is comparable with estimates from Madagascar (12%) and Myanmar (11%). The prevalence of severe wasting is comparable to data from northern Sudan (2.3%). In contrast, 1991 estimates of malnutrition from Baghdad were comparable with estimates from Kuwait (12% for stunting, 6% for underweight, and 3% for wasting).
The current nutritional situation among children in Baghdad is more
similar to lesser developed countries with a larger percentage of the
population residing in rural settings which may be a reflection of the
inability to maintain systems for sanitation and clean water under
sanctions. Due to the increasing problem of food insecurity and the
inability to repair the infrastructure for provision of sanitation and
potable water, the nutritional status of children in Baghdad will continue
to deteriorate unless the appropriate measures are taken to secure food
and to provide a safe environment. Moreover, it should be noted that the
nutritional status of children in southern and northern Iraq is likely to
be even worse than reported in Baghdad.
An FAO Mission visited Iraq from 25 July to 1 September 1995, with the task of assessing the crop and food availability situation and investigating the nutritional status of the population. As recommendations had been made by a previous nutritional assessment mission in November 1993 for establishing a nutrition surveillance system and as no action had been taken in the intervening years, the feasibility of attempting to establish such a system was re-examined. The Mission received full cooperation from the staff of the UN agencies (UNICEF, UNDP, WFP, WHO) based in Baghdad and elsewhere in the country and from the government agencies and NGO's involved in food and nutrition activities. The Mission travelled extensively in various parts of the country including the Northern Governorates, visited health, agricultural and food distribution facilities, interviewed farmers and concerned professionals and carried out independent market surveys for an assessment of food availability and market prices. With the cooperation of the Nutrition Research Institute, the Mission conducted a nutrition survey in the Baghdad area to investigate the nutritional status of children. The Mission also reviewed existing data on nutrition and health status available from a wide range of governmental, UN and NGO sources.
The integrated nature of the Mission should be noted in that a food availability and crop assessment and an assessment of nutritional status was undertaken simultaneously. Although Mission members were present in Iraq between 25 July and 1 September on no occasion was the whole Mission present at the same time. The crop and livestock assessment was performed between 25 July and 15 August by Dr. Khan who then returned to Rome. Dr. Smith Fawzi joined the Mission on 20. August to be involved with planning and performing the nutrition survey. The interdependence of food, agricultural and health considerations is fundamental. For the assessment of food availa- bility and nutritional status, under conditions as are currently present in Iraq, the interaction between agricultural, nutritional, and economic considerations is of major importance. The team endorses this approach for future missions of a similar nature when timing in relation to harvest is suitable.
The Mission was composed of:
The Republic of Iraq is located in South West Asia, bounded by Turkey in the North; Iran in the East; Syria, Jordan and Saudi Arabia in the West; with Kuwait, Saudi Arabia and the Gulf in the South. The three Governorates in the north, Erbil, Dohuk and Suleimaniya, comprise the Region and are, for the present, outside of the jurisdiction of the Government of Iraq (GOI). The total area of Iraq is 438,320 sq km and there are three major regions: the mountainous region, the alluvial plain and the desert plateau. The climate is continental and subtro- pical and is characterized by cool to cold winters and hot to extremely hot, dry summers. Rainfall is highly erratic in time, quantity and location and ranges from less than 100 mm to about 1,000 mm/year. The substantial variation in amount and distribution of rainfall increases the risk to rainfed production. Much land area, even that previously reclaimed, is presently being lost by waterlogging and increasing salinity.
The total population of Iraq is approximately 20 million with 42% being aged less than 14 years. The population is mainly urban (71 %) and has an annual growth rate of 2.7%. Adult literacy is high (95%) and there are 22 Universities and Institutes of Higher Education. Until 1990 there were very significant advances in the provision of health care and major construction projects gave the country a first class range of medical facilities in both large towns and also through a series of clinics in rural areas. As a result of these improvements, infant mortality rate (IMR) had declined to a value of about 40 per 1,000 live births by the late 1980s. Following five years of the economic embargo imposed in August 1990 by the Security Council of the United Nations, the Government estimate for the mid-1990s is that IMR is now 92.7 per 1,000 live births.
The Iraqi economy was dominated by the oil sector from the early 1950's until the major cessation of exports in 1990. During this period there was improving prosperity for the vast majority of the population. With the embargo on oil exports (except for limited sales to Jordan) economic decline has proceeded rapidly over the last several years and is reflected by the exchange rate of the US$ which currently (August 1995) is in the order of 1 US$ = 2,000 ID. This decline has precipitated severe problems throughout the whole country which were described by earlier missions in 1993 as demonstrating pre-famine conditions. In Iraq the agricultural sector has been given high priority in attempting to ensure food security through greater self-sufficiency. Despite this a high dependence on imported food remains.
Since 1993 the situation has become much worse for the majority of the
population, beggars and street children are seen widely, crime has
increased and infantile malnutrition can be observed in both hospitals and
the general population. In Iraq, catastrophe has been avoided by the
widespread availability of the Government food ration. This Government
ration is not available in the autonomous region of the North and all food
there must be purchased on the open market. For this and for a number of
additional reasons which include factional fighting, the decline in
external assistance, high prices and many previous government employees
not receiving salaries, child undernutrition and malnutrition is also
widespread in the north, especially for the poor.
An earlier forecast by FAO Representation in Iraq that the 1994/95 cereal output would be larger than last year's based on good performance of rainfall and increased efforts by the government and international organizations, has not materialized. The total cereal production in 1994/95 is estimated at 2.5 million tons, about 10 per cent lower than last year's production and about 16 per cent lower than the average harvest during the past five years. Compared to 1989/90, the last year before the embargo, the cereal production in 1994/95 is down by about 27 per cent (Table 2). Moreover, the consumable cereal output in 1994/95 is further reduced because of much larger than usual presence of non-grain impurities such as dust, stones, straw, weed seeds and remains of insects/pests. By examining samples of wheat and barley from stores, seed processing units and silos, the Mission found non-grain impurities of up to 20 per cent in certain cases while, in the case of the mechanically harvested crops in Iraq, about 5 per cent would be an acceptable level.
Both the total cropped area and the per hectare yield in 1994/95 are lower compared to 1993/94 (Table 1 and Table 3). Although per hectare yields of both wheat and barley, the two main food crops of Iraq respectively accounting for about half and about on-third of the total cereal output, were somewhat higher compared to last year, a steep reduction in the acreage under both outweighed the gain in yields, causing a reduction of about 8 per cent in the output of each. In the case of rice and maize, which together account for 15-20 per cent of the total cereal output, the opposite has occurred, i.e. an increase in acreage and a proportionally larger decrease in yield, with the result that the output of each has declined.
South and central Iraq accounts for 78.7 per cent of the total 1994/95 cereal output, while the autonomous northern region (governorates of Dohuk, Erbil and Suleimaniya) for 21.3 per cent. Per hectare yield is somewhat higher in the northern region compared to south and central Iraq for both wheat and barley but not very significantly so (Table 4 and Table 5). The main problems faced are virtually the same in all the regions.
Prior to the embargo the Iraqi population were accustomed to highly subsidized imported foods with only about 30 per cent of its cereal consumption being from domestic production. The government has been unable to continue with this practise and government policy is now to increase domestic food production to feed the population. Government efforts to encourage and facilitate agricultural production includes the raising of purchase prices which rose very sharply in May 1995 to provide incentives to the farmers (Table 6). Farmers must, according to regulations, sell all their wheat, barley, rice, maize and sunflower to the government at the prices fixed by Council of Ministers. Farmers interviewed have indicated that they are reasonably satisfied with the prices currently being paid. However, under increasingly adverse input supply conditions, their costs of production are increasing.
International organizations, mainly FAO, have extended some help toward raising agricultural production in Iraq. For example, about 276,000 donums (69,000 hectare) in Nineveh governorate, which produces about half the country's total cereal output of mainly under rainfed conditions, were aerially sprayed against sunpest in 1995 with assistance from FAO. In addition 386,122 donums (96,530 hectares) were ground sprayed. The efforts of both the government and the international organizations are grossly inadequate in relation to the problems faced by the agricultural sector of Iraq. The main bottlenecks include lack of farm machinery - tractors, combine harvesters, irrigation facilities, drainage pumps, sprayers, flour milling machinery - and their spare parts, and critical shortage of quality seeds, fertilizers, pesticides and herbicides. These problems are common and serious throughout the country.
In the south in such provinces as Basrah, Nasiriyah, Kerbala, Najaf and also in places not very far from Baghdad, where agriculture is mostly under irrigation, an additional serious problem is salinity and water- logging. Before 1990, some 0.75 million hectares were reclaimed under drainage/irrigation schemes, and further 2.25 million hectares were to be reclaimed over the following few years. After the embargo, all irrigation and drainage programmes had to be stopped and thus no new lands could be reclaimed. It is also not possible to maintain the already reclaimed lands because of the failure to keep many pumping stations working, mainly due to a shortage of spare parts. Nor has it been possible to maintain already constructed drainage networks, let alone constructing new ones.
During field visits in the above mentioned provinces, the Mission saw in many places vast expanses of waterlogged lands and white sheets of salt stretching across fields and along road sides. In fact, about half of the 0.75 million hectares reclaimed earlier have returned back to marshy lands unsuitable for agriculture. The other half also faces similar prospects unless the pumping stations can be put back into operation for which spare parts are urgently needed. Also, new pumping sets are needed to replace those which are no longer repairable. One typical example of pumping facilities getting out of commission is Husseinia Pump Station, which, among others, was visited by the Mission. The station has 10 pumps, but only 3 are now in operation. The other 7 cannot be operated because of nonavailability of spare parts. Even those now in operation are not in a very good condition and may break down soon. This pump station had drained and brought under agriculture 25,000 hectares before 1990. With the pumping capacity declining, about 10,000 hectares have been submerged again and now look like a lake. Another 5,000 hectares in fast getting waterlogged.
The above example reflects what has been happening to most of the pumping stations established before the embargo. Dams and barrages are also facing electrical and mechanical problems, again mainly due to nonavailability of spare parts. Iraq badly needs an efficient irrigation system particularly in the south as well as to reclaim lands and to maintain the reclaimed lands to increase food production. Hence, the importance of irrigation/drainage schemes cannot be overemphasized. At a minimum, arrangement should urgently be made to enable Iraq to import spare parts and new pumping sets, as required, to return to back into full operation all the existing pumping stations and irrigation facilities.
Obviously, the main constraint on imports of machinery and other agricultural inputs is lack of foreign exchange as a result of the international embargo on oil import from Iraq. This is compounded by the need to obtain clearance from the UN Sanctions Committee on a range of imports, particularly non-food items. The Mission was informed that an agreement with a foreign company for the purchase of 300,000 tons of rice, to be paid for out of Iraqi frozen assets after the lifting of the embargo, was blocked even though it was first cleared.
The failure to import machinery and spare parts over the past 5 years has plunged the technological state of agriculture as well as of other sectors to a precarious level. Some machinery are still being used through an ingenious cannibalism whereby parts of broken machines are used in others to keep them running and the production process going. But even that is now becoming increasingly difficult. Lack of machinery has thus seriously affected preparation of land, irrigation, pest control and harvesting in 1994/95 and the ongoing post harvest processing of grains. Mission members also observed machinery in such poor condition that could cause serious injuries to the operators at any time during usage. The observed low yield and poor quality of cereals are the result of failure to procure and supply quality seeds, fertilizers, pesticides and herbicides.
With food supplies available under the rationing system meeting only about onethird of the usual food energy needs of Iraqi people, vegetables and fruits have assumed increasing importance in the diet of the people. As a result, demand for and prices of vegetables have increased generating more attractive profit margins. Reflecting this development, there has been an increasing emphasis on vegetable production. The area devoted to vegetables has increased from about 8 per cent of the total cultivated area in 1989/90 to about 9 per cent in 1994/95. But the increase in area was largely offset by a decrease in yield and lower quality of the produce. Non-availability of vegetable seeds is by far the most important constraint, followed by a lack of plant protection chemicals and spray pumps, herbicides, and fertilizers mainly of compound types. Use of urea alone, when available, has been aggravating the alkalinity of the soils, resulting in low crop response and low yields. Large scale weed infestation and insect attack has reduced yield and quality. The main characteristics noted by the Mission during visits to vegetable fields include: low plant population because of poor quality of seeds used and insufficient land preparation; thin and weak plant stems and leaves because of low and unbalanced use of fertilizers; increased competition with the growing weeds; and high percentage of damaged plant leaves and fruits because of non-availability of plant protection chemicals and equipment.
There is no firm estimate of annual production of vegetables. Estimates available indicate that it has varied between 3.2 and 3.5 million tons during 1991-95.
The estimated number of fruit orchards including citrus, date palm and a variety of other fruits in 1989 was 84,000 (with average numbers of tree per orchard about 832 in 1989) compared to 219,000 in 1978. The estimated productive number of orchards in 1995 is about the same as in 1989, but the annual production has since increased and ranged from 1.1 to 1.2 million tons during 1990 - 1994. The total production in 1995 is expected to be 1.3 million tons (Table 7). The Mission notes with concern that the farmers have been putting in extra efforts to manage their orchards during the postembargo period (1990-1995), but to little or no avail. In the absence of necessary machinery and chemicals, they cannot do much against increasing weeds and infestation by insects and pests. In some areas also, orchards are suffering from waterlogging and salinity.
Dates are the most important fruit in Iraq. About 400,000 tons of da- tes were exported annually before the embargo. In addition, it is an important component in the food intake of the Iraqi people. Although export of dates is currently negligible, there is a strong domestic demand for it in view of its value as a supplementary food. Available statistics show that the number of date palm trees were damaged and reduced from 21.403 million in 1981 to 15.911 million in 1991 during the period of Iran-Iraq war (1980-1990). The estimated number of trees in 1995 is about 18 million. Under conditions of food shortage due to the embargo, there have been attempts by farmers to improve the management of date palm trees; they cannot however, do very much due to lack of machinery and spare parts, insecticides and herbicides.
An abundance of weeds is infesting the date palm fields and are harbouring insects/pests such as Humaira and Dubas. This is adversely affecting the production of dates. Early this year, a build-up of both the Humaira and Dubas insects in palm trees was noticed in south of 32. parallel and an assistance for the aerial spray was sought from FA0, which was arranged. A campaign started on 23 May 1995 in Misan province and expanded to Basrah, Thi Qar, Al-Muthana and Al-Qadisiah and ended in Najaf province on 6 June 1995 covering some 40,175 ha. This has been of significant assistance in checking the outbreak of the two insect types. The output of dates in 1995 may be somewhat higher than for 1994 and is estimated at 650,000 - 700,000 tons (Table 8).
The animal population in Iraq has declined steeply since 1990 (Table 9) under the post-embargo conditions. Between 1990 and 1995, the number of cows declined by 34 per cent, the number of buffaloes by 46 per cent, the number of sheep by 42 per cent, and the number of goats by 81 per cent.
Traditionally, Iraqi people have depended heavily on meat and other livestock based products in their regular diet. The embargo has reduced the availability of red meat, poultry meat, milk, eggs and fish to very low levels, as shown in Table 10. Critical shortage of animal products have caused their prices to increase steeply and beyond the purchasing capacity of the majority of the Iraqi people. Most Iraqis are unable to eat meat or poultry meat even once a week.
The main factors limiting livestock and poultry production are critical shortages of feed, veterinary services and drugs, and machinery and equipment and their spare parts. Moreover, a further constraint is gaining in importance and that is the diversion of pastures into grain production. The production of milk and milk products have virtually collapsed due to poor health of milking cows and lack of equipment.
Before the Gulf war (1990), 2.5 million tons of feed stuffs (corn, pro- tein concentrates, soybeans, wheat bran and barley) were available, but now none can be imported or spared from the local harvest under the existing food shortages. Livestock farmers have, however, been advised to try to save the animals using whatever other alternative feed they can find. The central meat supply system has collapsed. The animals are now slaughtered on road sides openly and indiscriminately, creating health hazards. Reportedly cattle are being smuggled out to neighbouring countries because of the weak Iraqi dinar and the attractive profits that can be made from smuggling.
In poultry production, there were 8,353 small and 25 big chicken projects during the pre-Gulf war period, which provided estimated 1,688 million eggs, 106 million hatching eggs, and 250,000 tons of chicken meat. However, many of these projects are now just empty compounds with some remains of equipment and machinery scattered around.
Fish production has also been seriously affected. The only central facility for rearing and supplying fish fingerlings to fish farmers and to rivers, ponds, lakes and dams to renew and maintain the fish population in the country is now functioning only at half its capacity. The seasonal capacity of this fish hatchery was 50 million but the deterioration of its machinery, equipment including laboratory chemicals and feed and hormone supplies, its performance has drastically declined.
Domestic production of basic foods is grossly inadequate to meet national requirements - the shortfalls for 1995/96 are: food grains 66 per cent, pulses 58 per cent, vegetable oil 61 per cent, poultry meat 91 per cent, fish 92 per cent, eggs 92 per cent, milk 60 per cent, tea 100 per cent, sugar 90 per cent, and baby milk 100 per cent (Table 11).
Before the embargo, the country was, as noted earlier, heavily dependent on imports of basic food stuffs. As a result of the embargo, the country's ability to import food stuffs has declined drastically despite some flexibility being allowed for food imports. With a view to ensuring a minimum of food availability to the population as a whole, the government of Iraq introduced a public food rationing system with effect from 1 September 1990, i.e. within less than one month following the imposition of the embargo on 2 August 1990. It provides basic foods to the population at 1990 prices which means they are now virtually free. The food basket supplied was increased from the original lower levels to the 1993 level shown in Table 12, that provided 53 per cent of the 1987-89 average per capita food energy availability. The basket for adults was sharply reduced on 24 September 1994, presumably due to increasing difficulties in ensuring adequate supplies. Vegetable oil was however increased by 25%. This reduced basket has been supplied until the present and provides only some 34 per cent of the average 1987-89 per capita food energy availability.
Not only does the ration basket provides only about one-third of food energy needs, but being carbohydrate-based it is deficient in essential micro-nutrients and animal proteins. Hence, while the rationing system has forestalled the occurrence of any massive famine under conditions of critical food shortages and high food prices since the embargo, it has not checked increasing malnutrition and morbidity in a large section of the population which is too poor to adequately supplement the rations with other essential food items.
About 3.5 million people, comprising all civil servants in active service, military, police and security and other elite forces, civil servant pensioners, military pensioners, social welfare beneficiaries, and war veterans with a 60 per cent or greater disability also have been receiving a monthly allowance of ID 2,000 (equivalent to one US$ at the current free market exchange rate) since 1 October 1994. This allowance, however small, is certainly a welcome relief for those who receive it. However, 17.2 million people are not covered by this programme, with many of these being in extremely difficult economic conditions. Of these, some 3.6 million people of the northern region are not receiving any, or only negligible, food supplies through the public rationing system. However, the northern farmers are not required to sell their food-grains to the central government.
The food basket supplied through the rationing system is a life-saving nutritional benefit which also represents a very substantial income subsidy to Iraqi households. The monthly subsidy to a household of 5 adults is ID 42,895 and for one of 6 members including one child under one year of age amounts to ID 58,912, when current (August 1995) prevailing market prices are used (Table 13).
The annual cost for 1995/96 to the government in purchasing the foodgrains from the farmers and storing, processing and distributing flour and rice is estimated to be a hefty ID 185.7 billion. It has been assumed for this estimation that the total quantities of wheat, barley, maize and rice produced in south and central Iraq in 1994/95 will be purchased and paid at average prices of ID 100,000, ID 60,000, ID 135,000 and ID 70,000 per ton for wheat, barley, paddy and maize respectively and another ID 5000 per ton spent in processing, storing and distributing food stuffs. An estimated ID 158 million only is received by the government from ration sales, leaving a net cost of ID 185.5 billion to be incurred by the government. Another monthly subsidy of ID 7 billion or yearly subsidy of ID 84 billion is being provided under the monthly allowance scheme that covers some 3.5 million persons.
In addition, vegetable oil, sugar, tea and baby milk distributed have to be purchased by the government. While some parts of the supplies of these commodities may be procured from the domestic markets, import necessarily has to be the major source given limited or no domestic production in most cases. Assuming that the import requirements to meet the ration obligation are the balance over domestic production in the case of wheat flour and rice, 50 per cent of the requirements of sugar and vegetable oil, and all of tea and baby milk (domestic production of these two commodities is respectively none and negligible), a rough calculation shows that US$ 258.1 million will be needed for 1995/96 on this account for the south and central Iraq alone (see Table 14 for the requirements and Table 16 for CIF import prices). There are still the costs to be incurred in ID for procuring the other 50 per cent of vegetable oil and sugar from the domestic market and in storing and distributing these commodities, which should amount to several billion ID.
Thus the total ID required for meeting the obligations under the rationing system for the south and central Iraq alone for 1995/96 would be ID (185.5 + 84) or 269.5 billion together with the US$ 261.5 million referred to above. The ID cost would be larger than 269.5 billion because this amount does not include the costs of domestic procurement, storage and distribution (of the envisaged 50 per cent) of sugar and vegetable oil. For the whole country, the costs involved could be 15-20 per cent larger, given that the population of northern governorates accounts for about 17.5 per cent of the total Iraqi population.
So far the public rationing system has been performing efficiently, with negligible margins of omission or commission. But the burden of the costs involved is increasingly becoming too heavy for the government. The collapse of ID is largely due to these heavy costs in addition to the cost of running the usual government functions. Printing of notes has been resorted to as a way of keeping things moving. This, however, is unsustainable. Furthermore, because the country is unable to resume international trade and earn foreign exchange by selling oil, the collapse of the whole public rationing system is threatened. The ration basket has already been cut by about a third, reducing even further the low levels of food energy and protein available to the people. The situation is serious; and a collapse of the system will spell a catastrophe for the majority of the Iraqi population.
In view of the precarious condition of the vulnerable groups, emergency feeding programmes, such as those of the WFP, have been continued since April 1991. The ongoing WFP EMOP, which has a requirement of 102,285 tons for a beneficiary caseload of 1,325,000 and began on 1. April 1995, will terminate on 31. March 1996. This is being implemented under two phases - 1. April 1995 to 30. September 1995 and 1. October 1995 to 30. March 1996. Due to lack of adequate donor response, the planned food distribution cannot be maintained. As a result, the number of beneficiaries for the 1995 summer months has been reduced to 350,000 If rom 750,000) in the north and the food allocation (kg/person/month) reduced from the four commodities of 12 kg wheat flour, 0.9 kg pulses, 0.9 kg vegetable oil and 0.3 kg sugar to the two commodities of 5 kg wheat flour and 0.5 kg pulses. This reflects a reduction in the daily food energy value from about 1,800 kcal/day to some 650 kcal/day. In centre and south, the number of beneficiaries has been reduced to 250,000 (from 550,000) with a reduced food ration level distributed every other month instead of on a monthly basis. The availability of food has not permitted even this reduced level of assistance. Thus, there will be no food distribution in the north in August 1995 and has been none in the centre and south during June- August 1995.
The prospects of receiving adequate donor support is bleak and WFP food assistance may further dwindle in the coming months. However, WFP is keeping the number of targeted beneficiaries at 550,000 in the centre and south and 510,000 in the north - a total of 1,060,000. WFP has, however, so far been able to provide food to those in hospitals and institutions. In order to make the available supplies go as far as possible, WFP is now directly distributing food in the north, which was previously handled by CARE; and the cost of distribution has come down to US$ 23 from US$ 45 per ton. The food assistance being provided by other organizations such as some NGOs particularly in the north, is extremely limited.
In fact, WFP's targeted 1.06 million people for food distribution over the coming months account for only 5 per cent of the population of Iraq. It looks certain, in view of the observed donor apathy, that the number that can be served will be much smaller. Actually not only those targeted by WFP, but also a very large proportion of the population of Iraq is in desperate need, and their conditions are worsening because of their deteriorating purchasing power and the continuous rise in food prices. The situation is so grave that it cannot be met through UN and NGO food assistance. The only sensible solution to the precarious food supply situation is to enable Iraq, a potentially rich country, to import foods to meet its entire requirements.
The rations are grossly inadequate both quantitatively and qualitatively. People must therefore supplement their food intake by purchases from the open market. Prices of basic food stuffs have increased phenomenally - in all parts of the country.
The Mission carried out independent market surveys in Baghdad and several governorates in the central and south Iraq and also in the north. The prices are not only very high, but also extremely volatile. Some prices have gone up by 15 to 30 per cent over a two week period, as indicated by spot surveys conducted in Baghdad on 14 August and 27 August 1995.
Prices of basic food stuffs as of end August 1995 are reported and compared with prices in June 1993 and July 1990 in Table 15. It is mind boggling that the price of the most basic food item, wheat flour, has risen by 11,667 times compared with July 1990 and by 33 times compared with June 1993. Prices of rice, vegetable oil, milk powder, and sugar have risen by 4,375 to 5,500 times compared with July 1990 and by 37 to 58 times compared with June 1993. Prices of poultry meat, eggs, tea, potatoes, and lentils have risen by about 1,000 to 2,000 times compared with July 1990 and by 37 to 62 times compared with June 1993. Red meat and fish prices have risen the least respectively 193 and 240 times compared with July 1993 and 17 to 21 per cent compared to June 1993.
The Mission during its visits to markets in Baghdad, Mosul, Basrah, Amarah, Nasiriyah, Najaf, Dohuk, Erbil and Suleimaniya saw reasonable supplies of food stuffs in shops, except in Erbil where some shortages were noticed. Apparently, the private sector is active in procuring and displaying supplies. But the prices everywhere are out of the reach of the common people. The Mission noticed very little purchases being made in the various markets. If there were adequate purchasing power in the hands of the people, the available supplies might not last very long - of course, in that case, more supplies will be brought in by the traders.
That the national and family economies are in crisis can be easily gauged from the fact that the Iraqi Dinar has experienced a free fall in the unofficial exchange market. Currently at 2,000 Dinars to the US dollar, the unofficial exchange rate is 6,400 times the official ex- change rate. A large part of the recent steep increases in the market prices of food stuffs and other commodities, which are mostly imported by traders who have to mobilize their own foreign exchange resources for imports, can be attributed to the collapse of the ID.
There has been a simultaneous collapse of the personal incomes in terms of purchasing power. In central and south Iraq, the monthly emoluments (salary + allowances) of lower level government employee are ID 500-600. The average monthly emoluments of all civil servants are about ID 5000 (US$ 2.50 at the unofficial exchange rate). There is very little work in the private sector. Unskilled workers can earn about ID 500 a day provided they find work. Interviews with groups of unskilled workers, waiting on street corners in the hope of being picked up by prospective employers, in Baghdad and other places have revealed that it is not often that they find work for more than one day a week. In the northern region, the situation is equally bad if not worse. Civil servants in Erbil and Suleimaniya have not been paid salaries over the past several months. In Dohuk, however, civil servants have been receiving their salaries, but these are too low in relation to the prices of food stuffs and other necessary products. Jobs in the private sector are very hard to find and it should be remembered that the basic government food ration is not available to the people in the north. Also WFP assistance for most of the vulnerable people has been substantially cut back on account of supply shortages caused by inadequate donor responses. The economic problems of the region has been further compounded by the recent fighting and continued antagonism between the two Kurd factions PUK and PDK, as well as the cross-border actions of Turkey in pursuit of the PKK.
There is a prevailing view and it has been confirmed through investigations conducted by the Mission that, in general, rural people, particularly farmers are doing better than the urban population. Farmers can, for example, grow vegetables, raise chicken or cattle towards augmenting their food availability and incomes from crop production. On the other hand, in urban areas such opportunities rarely exist. The ur- ban population accounts for about 71 per cent of the total population of Iraq, of the 29 per cent rural population, farmers constitute about three-quarters. That is, about 21 per cent of the total population are farmers. The other 8 per cent or so living in rural areas are in bad shape in the absence of income earning opportunities. Of the urban population, about 10-12 per cent or about 7-9 per cent of the total population may be doing very well through trade and access to other attractive means of making money. Hence, when the farmers (21 per cent) and the rich (7-9 per cent) are excluded, about 70 per cent of the total population is in precarious conditions. Many have been surviving by selling household goods and personal effects; but this option is also closing for most of them because either they have run out of things to sell or buyers are becoming hard to find. It was observed in a collective village in the north that people were literally selling their houses, i.e. bricks and other materials of their houses, with more than one family then congregating in a single remaining room.
It has been shown earlier that the ration basket for an adult that provides 34 per cent of the normal food energy intake by an Iraqi costs ID 8,588 at current market prices. If the shortfall of 66 per cent were to be made up by a family of 5 adults from the same food items, i.e. without considering the quality of the foods, it would need ID 83,354 to purchase the necessary supplies from the market and the amount would be larger if a more balanced diet were to be secured. If the family has a baby under one year for whom the ration (baby-milk powder) provides about 50 per cent of the need, it would need another ID 16,020 for procuring the additional food for the baby. These sorts of financial resources are clearly beyond the command of the large majority of the Iraqi population. The solution lies in adequate food supplies in the country, restoring the viability of the ID, and creating conditions for the people to acquire adequate purchasing power. But, these conditions can be fulfilled only if the economy can be put back in proper shape enabling it to draw on its own resources, and that clearly cannot occur as long as the embargo remains in force.
Prior to the Gulf crisis, Iraq produced about one-third of its basic food needs and spent about US$ 2 billion to import the balance of the requirements. Since then, despite emphasis on increasing food production, the situation has deteriorated due to many problems relating to agricultural inputs as has been explained earlier. It is estimated that Iraq will need US$ 2.7 billion to import basic foods to meet the shortages in 1995/96 (Table 16). Short of lifting the embargo, the only other source of such a huge amount of foreign exchange for Iraq is its frozen assets, the use of which is strongly encouraged by the Mission to enable Iraq to import the essential basic food stuffs to feed its population.
Before 1990 the food industries in Iraq were divided into three major areas under the control of different Ministries and Departments. These were: a) the Department of Industry: in which the State Organization for Food Industries gave oversight to the State owned food factories and companies; b) the Department of Trade and Commerce which was concerned with flour and bread production and distribution through the Iraqi Wheat Board and c) the Department of Agriculture which was concerned with the production and distribution of meat, fish and poultry and controlled the importation and distribution of feed and other veterinary requirements
The State Organization for Food Industries controlled factories in the major production areas of dairy, sugar, vegetable oil, tobacco, soft drinks and breweries, and canning. A large range of products were produced and quality generally met international norms. Both the dairy and the canning sectors produced baby foods. The State Organization was abolished in 1990 and the food industry as a whole was returned to the private sector. Since that time, for a number of reasons related to the embargo, production has dropped considerably and is generally less than 10% of pre-1990 levels. Because of specific restrictions to conserve sugar, in some sectors (chocolate, sweets, ice cream and sugar containing soft drinks) production is almost zero. Sugar production itself is very low and is probably only at a level of 2-3% of the 450,000 tons per year produced before 1990. Major problems in the canning sector are in the availability of cans and packaging and only tomato products and date syrup are produced in any quantity. It has generally been more profitable to import products, both legally and illegally, from the cheapest sources. These may often be those past their expired dates or declared unfit for human consumption.
The Department of Trade and Commerce was originally responsible for importation of foods such as rice, beans, lentils, canned foods and many other food products of the best quality and highest standard. Because of foreign exchange limitations the main priority is now to provide the amount required in the ration with much less regard for quality. Many dry foods sold in the market at the present time may thus be contaminated with aflatoxin and other mycotoxins and the public health authorities often do not have the facilities and transportation to perform adequate testing. The export of dates was another concern of the Department of Trade: very little is now exported and most of the reduced production is consumed locally by humans and by animals as feed. One of the few growth areas in production is for date syrup which, because of the non-availability of sugar for sweets, is sold widely as a substitute for jams and preserves.
Additional problems for food production from small manufacturers in the
private sector lie in poor quality control and the increasing use of
non-food grade materials for food use. The latter can include emulsifiers,
thickeners, dyes and other chemicals. Regulations are unable to be
enforced and major food safety hazards exist. FAO help may be needed in
re-establishing adequate mechanisms for food safety. These problems, while
real, can only have low priority when the Government is faced with the far
more basic task of providing a daily ration of food to meet food energy
needs.
Because of difficulties reflecting both production and the limited availability of foreign exchange the quantity of food in the ration was reduced significantly in September 1994. The composition of the ration is shown in Table 13. Despite the fundamental importance and wide availability of the ration, such a ration provides only about one-third of the food energy that was available prior to the war and is of poor nutritional quality with a lack of animal proteins and micronutrients.
The rationing system is a highly centralized system in terms of its design. Distribution of rations, however, is decentralized through distribution centres that provide rations to 50,000 private retail stores which in turn distribute monthly rations to households within their area. Transportation of these rations from the warehouse to the retail store is provided by the private sector, and paid for by the government. The warehouses are government owned, and scattered throughout the country.
The system is highly effective in reaching the population; according to the Minister of Trade errors of duplication or omission occur only in 1.7% of cases. Each Distribution Centre is equipped with a computerized list of those entitled to receive rations. These lists are periodically updated to take into account changes in household structure and location. Most persons reported receiving rations on a timely basis with allocations corresponding to the number of persons in the household. For example, those households involved in the nutrition survey in the Baghdad area, women in the market place, and farmers in areas as far apart as Basrah and Mosul all reported receiving their rations. In the autonomous region of the north government rations were now virtually non-existent but, surprisingly, at several meetings with officials in the Northern Governorates the Mission was requested that the ration be restored. This was almost certainly because of the high prices for food, the lack of work availability and the reduction in WFP and NGO assistance to the north.
The ration is heavily based on cereals and requires supplementation with other foods to meet average nutritional needs. The highly subsidized ration represents a very large income supplement and represents an enormous cost to the GOI. The original ration contained more food items and provided more nutrients than the present ration. It should be noted that infant formula is only supplied when there is a child below 1 year of age in the household.
The comparison between the average daily supply of selected nutrients from the baby food supplied in the ration (1,800 g per month) with the daily requirements of selected nutrients for 0-6m and 6m-lyr child is shown in Table 17. It will be seen that these average about half the requirements or less, depending on age, for food energy and protein but can be somewhat higher for certain micronutrients because of the generally high level of fortification in the baby food products. Meeting the full needs for protein and for food energy is important for optimal growth of the young infant and for the prevention of malnutrition. Breast-feeding is always desirable and the very high cost of breast- milk substitute products in the market makes it very difficult for the poor to meet the nutritional needs of their infants when mothers do not breast-feed.
The nutritional value of the government food ration has been calculated using the most appropriate values for food composition of the items concerned with wheat flour reflecting the nominal composition of 60% wheat and 40% barley. Actual composition is poorer than this since the grain is contaminated with a mixture of weed seeds and non food material. The nutrient composition from food balance sheet data (53 food items) for Iraq (1988-90 average) was also calculated using appropriate food composition data. Comparison is also made with adult requirements. The United States recommended daily allowances for an adult male are, of course, not fully appropriate for the Iraqi population but they do serve as a convenient yardstick for comparing nutritional availabilities. These values are shown in Table 18.
It will be seen that the ration, being heavily based on cereal products, is not nutritionally balanced in relation to daily needs. While the food energy of the ration supplies 38% of adult needs and 43% of total protein, other nutrients, in particular vitamin A and vitamin C are almost completely deficient in the ration. The protein, mainly originating from cereal, is also low in Iysine and hence utilizable protein would be low. Even the pre-war diet, also heavily based on cereals as is typical for much of the Near East, was low in Iysine but was considerably higher than the present ration and would have needed less supplementation to meet daily utilizable protein needs.
Other nutrients such as iron and thiamine, which are adequately present in cereal grains, may approach daily needs even at the low level of food energy supplied. For iron the bioavailability would be low and the needs for females would unlikely be met. When compared to the nutrient availabilities immediately pre-war, the deficits in the ration are also clearly apparent. This is especially the case for vitamins A and C but calcium, folate and vitamin B 6 are also low. The inclusion of fruits, vegetables and animal foods in the diet is essential for meeting nutritional needs and agricultural production goals should be aimed at increasing the availability of these foods and reducing their cost.
The very low level of fat is also obvious despite the small increase in vegetable oil. Fat has a high food energy content and low bulk and is useful in increasing the energy content of cereal based diets and improving the bioavailability of vitamin A. There is no recommended daily allowance for fat but in order to supply 30% of the food energy as fat at 2900 kcal/day some 97 g/day would be needed; the 22 g/day in the ration thus falls far short of this value.
The ration supplies a very important part of daily dietary needs, especially for food energy and protein and has prevented catastrophe for the Iraqi people over the five years of the embargo. It is, however, far from being nutritionally balanced both in relation to daily needs and also in comparison with what was available in 1988-90. The foods needed to bridge the gap between the ration and daily needs are mainly fruits, vegetables, oil, dairy products, legumes and animal protein, all of which are expensive in the market place and, as a consequence of the reduced purchasing power for the majority of the population, are unable to be obtained in adequate quantities.
The accomplishments in health and nutritional status of the Iraqi population achieved over the last two decades in part due to the oil wealth are rapidly deteriorating due to prolonged sanctions. While food is readily available in markets the purchasing power of the average Iraqi has declined, especially for the salaried civil servants, pensioners and destitutes. The Ministry of Health estimates that 109,720 persons have died annually between August 1990 and March 1994 as a result of the delayed effects of sanctions. The Mission was unable to confirm these numbers. According to the Ministry of Health, the health and nutritional status of children has been seriously affected. Moderate to severe malnutrition using the criteria of <80% weight-for-age was 29% for children under-five, the percentage of low birth weight babies (<2.5 kg) is estimated at 21.1 % and infant mortality and under-five mortality are reported at 92 per thousand live births and 128 per thousand live births. In comparison, the infant mortality rate in 1989 was about 40 per thousand live births.
As a result of 5 years of sanctions, most of the Iraqi population is suffering from reduced food intake. Although basic food items are available in the market, prices are prohibitively expensive for most wage earners, pensioners and those that rely on monetary assistance from the Government. Thus the nutritional status of much of the population, especially the most vulnerable groups including children under-five, is in decline. The Ministry of Health has reported a significant increase in cases of malnutrition, such as kwashiorkor and marasmus and other micronutrient deficiencies. Monthly average numbers for kwashiorkor, marasmus and for other cases of malnutrition are shown in Table 19. The very large increases in all categories are obvious. Doctors in paediatric hospitals observed that before 1990 kwashiorkor was a rare phenomenon but is now common. The number of marasmus cases has also increased significantly and reflects the role of infections especially gastroenteritis in the summer months and respiratory infections in the winter. Total number of deaths and monthly averages for deaths of children under five years of age between 1989 and July 1995 are shown in Table 20. Average numbers of deaths can be seen to have increased dramatically over this period. These data were provided by the Government's health statistics department and are unable to be confirmed by the Mission. In view, however, of the malnutrition observed, the health hazards in the water supply, the degree of inflation throughout the period and hence the inability of many to purchase food together with the decline in the overall health care system, these data are plausible.
Several surveys which were carried out immediately after the war revealed high levels of malnutrition in hospitals and health clinics (Harvard Study Team, 1991). One drawback of these surveys was that they were based on hospital visits, and thus not representative of the nutritional situation of the overall Iraqi population. In August and September of 1991, the International Study Team conducted a nationwide survey of the nutritional situation among children under five years. Their results showed a considerable degree of stunting among children under the age of 5 years (21.8% of children under 5 years were below -2 SD from NCHS Ht/Age median values). However, the per- centage of children with weight-for-height below 2 SD (wasting) was 3.4% -- similar to the NCHS standard. The most vulnerable age group for all nutritional indices was between 12-23 months. Studies conducted between 1991 and 1993 show deteriorating nutritional status. A study conducted in May 1992 based on 6-9 year old school children in 19 schools in Baghdad serving different socioeconomic classes showed that those from low socioeconomic classes had the highest percentage of stunting (14.6 % ) (Naoush and Obeid, 1992). The authors noted a negative correlation between wasting and socioeconomic status. The z-score distribution for all three nutritional indicators (height-for- age, weight-for-age, weight-for height) had shifted to the left of the NCHS reference but did not suggest significant malnourishment. UNICEF assessed the nutritional status of children in the Wasit governorate south of Baghdad and noted that the percentage of wasting was higher in urban areas (4.6%) compared with rural areas (0.8%). Nutritional assessment of children in Al-Muthana governorate (adjacent to Wasit) showed that the percentage of wasting was 10.3% and infants under 6 months were seen to be most affected.
A survey was conducted in 1993 by the FAO mission in collaboration with the Nutrition Research Institute. This was in a less privileged area of Baghdad and covered part of the same areas in Saddam City that were examined by the 1991 International Team Survey. One hundred and twenty- one households were visited and a total of 506 subjects were measured: 194 were children under 5 years of age, 136 were between 5-15 years and 172 were above the age of 15 years. The results showed that for those under 5 years and using the criteria of Z score of less than -2SD as signifying malnutrition, 30% were stunted (ht/age), 35% were underweight (wt/age) and 16% were wasted (wt/ht). For those between 5-15 years the corresponding values were 33%, 31 % and 11 %. It was concluded by the 1993 mission that there had been a significant increase in both stunting and wasting among children since 1991 and that there was evidence of both chronic and acute malnutrition in children below 15 years of age.
In March 1994, the Ministry of Health conducted its first nutritional assessment covering 50% of all children under five enroling in kindergarten - 25% of the sample was from Baghdad and the rest from other governorates excluding the 3 northern governorates (30,089 children). The average height for 4-year olds was 92 cm and weight was 17.4 kg, indicating a state of chronic malnutrition. Since the sample represents those who attend school, the degree of stunting would be expected to be more severe in children who are not at school. As a further indication of economic decline and hence probable malnutrition in the community, the Mission noted a greater presence of street children selling cigarettes or other items, polishing shoes and begging in comparison to that observed in 1993.
According to Obeid (1994), the rate of stunting in the age groups 0-6 months and 7-12 months had increased compared with 1993. The rate of underweight in the age group 7-12 months was also higher than in 1993. However, there was no major change in the rate of wasting for these age groups. The Mission noted a few cases of marasmus in Mosul, Saddam Hospital. The hospital does not keep statistics on malnutrition, but according to the Head of the Paediatric Department the hospital has seen an increase in the number of cases that were referred as "failure to thrive" complicated with diarrhoea (A HREF="#tab21">Table 21). It was also noted that the hospital was seeing more cases of gastroenteritis in the 0-3 years age group. No cases of vitamin A deficiency were reported by this hospital.
The Paediatric Departments of the Saddam Hospitals were also visited in Amarah, Kerbala, Basrah and Nasiriyah. Many cases of both marasmus and kwashiorkor were observed in the wards along with cases of infectious disease such as typhoid fever and infective hepatitis which were associated with the generally poor state of sanitation. Some 30% of all admissions since mid-1993 have been for diagnosed malnutrition. Both marasmus and kwashiorkor presented many of the classically recognized signs. For kwashiorkor oedema especially of the face, legs and feet, thin and wispy hair and skin changes were all observed. Skin changes were, however, minimal compared to the severe flaky paint dermatosis with ulceration often seen in children from Africa. Severe wasting, especially visible in the ribs and limbs together with "old man faces" was seen in the marasmic children. Here weight-for-age was invariably below 60% (Gomez III) and when height/length was determined wt/ht was below 80% of the international median. Generally cases of kwashiorkor were older than 1 year while those diagnosed as marasmic were younger. All three hospitals were unable to operate at full capacity because of lack of facilities and medicines and were admitting the most severe cases. In addition, cases were discharged as rapidly as possible so as to free beds. Baby incubators were also suffering from lack of spare parts with only 8 from 36 being functional in the Basrah hospital. The situation in Amarah hospital had improved slightly since 1993 since 4 incubators were now functional. Vitamin A deficiency was reported as being on the increase in Basrah with both Bitot's spots and xerophthalmia having been observed. In both Basrah and Nasiriyah hospitals, CARE was providing daily food supplements for mothers and children. This consisted of 50g sweet biscuits (Marie), 25g milk powder and 30g processed cheese. While the value of the supplements was highly appreciated, it could create problems for the staff since the timing of programmes was intermittent and no long-term continuity could be planned for. It is an interesting reflection on the overall severity of the food shortage in the country that this supplement was also available to the doctors involved in treating the children. General shortages also affect the working of hospitals such as non functioning air-conditioners, absence of light bulbs and fluorescent tubes as well as the no longer functioning piped oxygen. In Basrah and Nasiriyah, sewage disposal was difficult because the tanker trucks needed spare parts and in Basrah, in common with much of the city, sewage backups were occurring. The hospital in Kerbala noted an increasing problem of rodents, flies and mosquitoes. Few insecticides or pesticides are available and those available are often potentially harmful.
In response to the worsening nutritional situation, UNICEF, WFP and MOH have proposed to establish Nutritional Rehabilitation Centres (NRC) in paediatric hospitals and primary health care centres. The following activities are to be undertaken: clinical examination and course of treatment (estimated for 20 days on average) and nutritional education for the mothers. Each child is expected to receive 50 gm/day of therapeutic diet, 50 gm/day of weaning food, and 100 gm/day of skimmed milk powder. The accompanying mother will also receive food which is regularly provided by WFP to hospitals. The Ministry of Health will provide the appropriate staff, monitor the programme and arrange for warehousing of WFP food supplies and distribution of weaning food and milk powder. Some of these centres were functional in the auto- nomous North with NGO assistance, but they were not yet established in Central and South Iraq.
Vitamin A deficiency has been of great concern to both the MOH and UNICEF, since the observation of even relatively few cases can be a reflection of a very serious underlying nutritional situation. No information had, however, been collected to document the prevalence of vitamin A deficiency in 1993 but several physicians had reported occasional cases of children observed with Bitot's spot as well as two cases of keratomalacia in Al-Mansour Children's Hospital. In 1994, the Nutrition Research Institute conducted a survey covering 8575 under-five children (4436 boys and 4139 girls) in 3 governorates of Nineveh, Baghdad and Basrah. The prevalence of night blindness was reported for boys and girls at 1.2% in Nineveh for both sexes, 1.7% for boys and 2% for girls in Baghdad, and 1.3% for boys and 1.2% for girls in Basrah. The WHO definition for a vitamin A deficient population is 1% prevalence amongst children. Moreover, Bitot's spots were reported at a level of 0.3% for boys and 0.1 % for girls in Baghdad. For Basrah, Bitot's spots were reported in 0.1 % of boys only. No cases of Bitot's spots were reported for Nineveh.
Vitamin A deficiency results from severe curtailing of intakes of both preformed vitamin A and of the various carotenoids especially _ carotene. This is often due to the high prices of food containing these nutrients. In 1993, the mission was informed that UNICEF, in agreement with the MOH, has agreed to distribute Vitamin A capsules: 100,000 IU at 9 months of age when children are vaccinated for measles and 200,000 IU at 18 months of age with the DPT booster vaccine. However, this programme has not yet been implemented in the field. The current Mission recommends that necessary steps should be taken immediately throughout the country to give Vitamin A to children to protect their health.
Goitre had been an endemic problem in Iraq, yet by 1979 goitre had been virtually eliminated in the country. A 1992 survey conducted in Mosul with the assistance of UNICEF revealed a prevalence of 40.7% among females. In 1993, a study of patients referred to Aloshah hospital in Baghdad revealed that about 56% of patients had several types of thyroid disease. Prevalence was highest among 15-44 years old. The government is planning to provide iodized salt. Nevertheless, his Excellency, the Minister of Health, while recognizing the importance of this and other fortification schemes indicated that his priorities must remain in ensuring that basic food energy needs are met.
The Ministry of Health has reported a categorical increase in the occurrence of low birth weight infants: 4% in August 1990; 19.2% in August-March 1993; and 21.1% in July 1995. The Nutrition Research Institute collected birth weights in January-February 1993 from 4 hospitals in Baghdad, and reported a low birth weight incidence of 19.45%. However, statistics that were made available to the Mission from the Ministry of Health, Nutrition Research Institute and several hospitals, did not include denominators necessary to calculate incidence rates. The 1993 mission had visited the Basrah governorate and obtained raw data collected from 60 health centres which included birth weights and total number of births by month for 1993. The incidence of low birth weight (based on 33,971 births, February to September 1993) was 3.86 per cent. The Basrah maternity hospital reported to the Mission that 4.8% of births (based on 13,089 births) were below 2.5 kg in 1994-95. Similarly, the Mosul Saddam Hospital reported an incidence of low birth weight of 3.7 per cent (Table 22), ranging from 1.0 to 4.2 per cent. A large percentage of births takes place at home, and thus there could be a low birth weight problem which is not visible.
In the Mission's household surveys, pregnant women were often noted to be suffering from anaemia. Iron fortification or iron supplementation would normally be recommended in these circumstances. In the present situation, in relation to the other priorities of ensuring access to food, it is unlikely that any action can be taken with regard to fortification. Greater availability of medication for iron supplementation could alleviate the problem to some degree.
Major surgical interventions have been reduced to 30% of presanctions levels. The Mission was told that a surgeon was allowed only one surgical operation per week. From the monthly average of 15,125 major surgical operations per month in 1989, the average reported by the Ministry of Health for January - July 1995 was 4,640. There is a general lack of anaesthetics and dispensable equipment such as gloves, syringes and catheters. Laboratory tests have also been affected by the severe shortage of reagents. Moreover, hospitals and pharmacies continue to suffer from the lack of life-sustaining drugs for treatment of cardiovascular diseases, diabetes and other metabolic and endocrine diseases. No member of the Mission was medically qualified but, nevertheless, the situation can be recognized as serious. It is recommended that a Mission, under the auspices of an appropriate agency, should be charged with examining the overall problems and deficiencies in the health care delivery system in Iraq.
The nutrition situation in the northern governorates of Dohuk, Erbil and Suleimaniya is still reported to be critical by UNICEF, various NGOs and regional authorities. The recent fighting between the two main political factions has disrupted the flow of resources and has also affected access to health care and food. Basic food items are available but expensive. Various groups including those classified as internally displaced due to the 1991 civilian conflict, refugees returning from Turkey and Iran, recent exiles from Kirkuk, residents of collective villages and civil servants are experiencing difficulties in meeting their nutritional needs. Because the government in Erbil has no current source of revenue, consequent to the factional fighting between the PUK and PDK, civil servants, including doctors and teachers, had received no pay for more than six months. Doctors were still working in the hospital without pay but were surviving on the incomes generated from their private clinics. Persons living in collectivized villages are unable to produce their own food - other displaced persons and poor urban dwellers are also entirely dependent on WFP food assistance. The Government of Iraq does not provide food rations on a regular basis to these governorates, and what is provided meets less than 0.1 % of the needs. In the North, all food must be purchased from the free market. Lack of fuel for heating is another major concern of the regional government and will become more acute as winter approaches .
In Dohuk, Suleimaniya and Erbil governorates malnutrition amongst children appears to have plateaued at around 20% using weight-for-height <90% of the NCHS median. This is according to two UNICEF 30 cluster surveys conducted in November 1993 and 1994. In the 1994 survey, stunting was found to be more prevalent in the 3-5 year age group (43.5%), while wasting was more prevalent among those 0-3 years old (31.5% for under 1 and 50.4% for 1-3 years). No significant differences were found between male and female children, and rural areas reported higher prevalence rates than urban areas. This may be due to diminishing humanitarian assistance to the rural sector and the adverse effect of political instability, in particular the internal conflict between PUK and PDK. Using the criteria of weight for height less than 90% median, values for malnutrition in the three governorates were 21.8% for Dohuk, 20.2% for Suleimaniya and 20.1 % for Erbil.
The Mission visited the main paediatric hospital in each of the three governorates. The Mission noted the presence of severely malnourished children in all three locations, many were marasmic and some were suffering from kwashiorkor. Statistics from the paediatric hospital are reported in Tables 23 and 24. There is a considerable degree of seasonal variability with winter months being the most severe. Dr. Robin Mills and Dr. Najmuddin Ahmed from UNICEF reported that paediatric admissions for malnutrition had substantially increased from the previous year in the nutrition rehabilitation centres. In 1994, there were 90-110 admissions per month per centre while in 1995 the number had increased to 150-200 per month. Thirty per cent of the malnourished cases were kwashiorkor and 70% marasmus, most were less than 3 years old. In the centres, malnourished children are given K-Mixll and vegetable oil. However, nothing is given on discharge and thus the same child often returns to the centres.
Impact Teams International (ITI) is an international NGO operating in Erbil. Working closely with the paediatric hospital, they administer a supplementary feeding programme and nutritional rehabilitation centre. Data for 1994 collected by ITI showed 6.8% severe malnutrition (children less than 70% weight-for-height) and 2.6% amongst children under five in the in-patient therapeutic feeding programme in Erbil's paediatric hospitals (Table 24). In addition, the total case load of malnourished children (less than 90% weight-for-height) in six health centres in Erbil ranged between a minimum of 1214 to a maximum of 1765. The prevalence of gastroenteritis was estimated at 46% and the case- fatality rate due to gastroenteritis was 32.9 (Table 25) per 100 child deaths. Malaria cases have also increased in the past year. In January 1995, 928 cases were reported for Northern Iraq and by June 1995 there were 4,124 cases. The spraying campaign, of the WHO malaria vector control programme in the Northern region had been completed in July 1995.
Sporadic cases of xerophthalmia are also appearing in hospitals in the North. However, UNICEF is administering vitamin A at the same time as measles vaccination. Vaccination coverage is satisfactory for individual vaccinations (BCG = 74.5%; DPT3 = 47.2%; measles = 60.1 %), but rates were low for a complete set and were estimated at around 32% by UNICEF staff. There are no reliable data on breastfeeding but according to Zerfas (UNICEF consultant) about 50% of infants were bottle fed.
Many of the pregnant women are reported to be anaemic. However, no data are available to validate this claim. A household survey conducted by Ward and Rimmer (September 1994) found that 11.6% of non-pregnant women had a body mass index below 18.5 in the population. This compares with around 3 to 5% in developed countries, and 5 to 15% in many developing countries. Moreover, a body mass index below 18.5 is associated with low birth weight babies and is also indicative of chronic energy deficiency. These data were compatible with expenditure information collected during the same period, and parallels the general decline in the purchasing power of the popu- lation. Not all groups are affected equally and only a minority (although a substantial one) has been sufficiently affected to result in adult malnutrition. In August 1995, the pockets of vulnerable groups had increased with the internal fighting, increased market prices and reduction in WFP food assistance.
The water and sanitation system remains critical throughout the country with the Basrah area (ca.1 million population) being the most serious. The basic reason throughout the system is the lack of spare parts for a variety of equipment which cannot be purchased without foreign exchange. Specific Sanctions Committee approval may also be required for most of the items. During the visit to Basrah the team were fortunate in being able to meet with Dr. Thanon Hussein Ahmad, Director General of the General Establishment for Water and Sewerage of the Ministry of the Interior who was in Basrah at the time. Dr. Ahmad is responsible for water and sewerage activities for the whole country with the exception of Baghdad. In Baghdad this is the responsibility of the mayor. In association with the local administra- tors, Dr. Ahmad arranged visits and the team were able to discuss the problems and limitations of the system in the head office for Basrah, visit pumping stations and see many local sites where huge areas of sewage water, often green with algae and sometimes showing visible faecal material, produced small lakes in streets and in common and domestic areas. These areas were grossly unhygienic and much of the city smelled badly as a result of these overflows. Overall it is our assessment that the situation concerning sewage disposal in Basrah has deteriorated even further since it was last seen and described as serious in 1993. This of course produces hazards to health which can seriously influence nutritional status in children. Under these circumstances it was not surprising that there were many cases of infectious diseases including typhoid fever and infective hepatitis in the hospitals as well as widespread gastroenteritis in the hot summer months and in consequence much nutritional marasmus. What remains surprising, however, is that the city has been able to avoid major epidemics in the presence of these atrocious sanitary conditions.
The team was informed that before 1990 the costs of imports solely related to water and sanitation equipment and spare parts for repair and replacement exceeded US$ 100 million/year for the whole country. In contrast, the total of aid for the same purposes during the last five years from international agencies has totalled less than US$ 10 million. Obviously in these circumstances, with both the need for permission and with little foreign exchange available for purchases, water and sewage systems are both in continuous decline. Contracts for various stages of the sewage renewal project for the Basrah area were agreed before August 1990 but delivery could not be completed because of the embargo. Although pipes may have been laid in earlier stages, many were never connected to the pumping system. Since they were believed to be functional many private connections were made to these pipes often leading to small sewage rivers in the middle of many streets and frequent backing-up of the liquid sewage into houses because of the high water table and the inability for natural drainage to occur.
Of more importance is the fact that under flat land conditions all sewage is required to be pumped. The team was informed that of the 65 pumping stations in the Basrah area none were able to operate at full capacity because of non-availability of spare parts for essential components such as the electric motors. A typical situation at a pumping station would show one functional pump from the four required to meet operational needs. Old motors are used extensively with parts being cannibalized in order to keep other motors functional. This procedure has its limits and a common sight throughout all Iraq, in almost all sectors, are massive piles of machinery, equipment, engines and motors which are providing spare parts to keep an ever decreasing number in service.
In the sewage and waste water disposal system street drainage and sewage lines eventually meet; with functional pumps this is no hazard but without pumps in very flat areas such as for Basrah such sewage backs up into houses and street drains producing foul smelling areas and very large health risks. The Governor cited families living on roofs as well as those using concrete blocks and planks in their houses so that they can live above the level of the backflowed sewage. Other areas of the town were described where the sewage accumulation was so extensive and prolonged that vehicles could partially sink. Even the hospitals are not immune since lack of spare parts for tanker trucks can prevent the special disposal of waste from these areas. Further environmental contamination is caused by the illegal use of private tankers that discharge raw sewage into waterways. The observations in the area made by the Mission confirm those made by previous groups, including various Needs Assessment Missions that the water and sanita- tion situation in Basrah continues to remain critical. Governmental and international agency activities attempting to alleviate the situation are extensive but are nowhere near enough to repair and replace systems that are so extensively devastated. The health risks are serious and continue to cause excessive and preventable mortality especially since intravenous fluid supplies are often problematic both in quality and quantity. Oral rehydration salt mixtures as provided by UNICEF were, however, generally reported as being sufficient.
In contrast to the general deterioration in sewage disposal, water availability may have marginally improved with the very large number of strategically sited water tanks throughout the city where drinking water is sold. Despite the slight increase in availability, water quality remains poor with 65% of samples failing either microbiological or mineral purity tests. Drinking water for Basrah city is from the Shatt al Arab which also receives discharged sewage. Because of the 2,000 ton/yr deficit in chlorine supply only drinking water is chlorinated often at a lower than desirable level. Sewage is discharged untreated. The population increase in the Basrah area resulting from those displaced from Kuwait and the border region has now stabilized but the overall water supply is much less than needed. The aim of the city ad- ministration is eventually to provide 450 l/hd but present supplies are only a nominal 150 l/hd which implies an effective availability of only some 80 l/hd. Tap water is available for part of the city, but it is considered of too high salinity to be potable or to be used for cooking. The quality has been improved since 1993 but still remains below acceptable standards. Bottled water is available but is too expensive for regular use, and consequently retail water facilities have arisen where potable water can be purchased. This water is purified by reverse osmosis in former factories with a current cost of 7 ID/l. It is of interest to note that this is 35 times the cost of petrol (gasoline) which retails at 0.200 ID/l. A major change since 1993 is the large number of water tanks which are placed throughout residential areas of the city and are now obvious everywhere. These have significantly improved availability of potable water in the city. The tanks originate from tanker trucks and are placed on bricks or concrete blocks; by attaching a hose and valve a retail outlet for water is established.
While these descriptions are for Basrah, similar problems exist to a lesser degree in many towns throughout the country and small sewage- water lakes were observed in Amarah, Kerbala and in Nasiriyah. In the Baghdad area water and sewerage systems are under the control of the Office of the Mayor. The Director General of water and sanitation of the city of Baghdad, Dr. Adnan Jabroo, met with the team and explained some of the problems. Many of the water pipes have been in place in excess of 50 years and are broken and blocked. High pressure thus cannot be used and with low pressure many areas of the city and upper stories of buildings are unable to receive water. Current effective availability of water is about 110 l/hd and because of the nationwide chlorine deficit levels have been reduced in water treatment from 2.5 mg/l to 1.5 mg/l.
For sewage disposal, in Baghdad there are 256 pumping stations for a city of some 4 million. Again the lack of spare parts and replacement units means that few are able to function at full capacity with consequent sewage backups in houses and in streets. The problem is acute in Saddam City and cases were observed by the team during the nutrition survey. Much raw sewage is now discharged untreated into the Tigris. The hazards of water supply and sewage disposal are nationwide and the effects on health are serious. As an example government statistical office figures show 1819 cases of typhoid fever in 1989; this had risen to 24,436 cases in 1994. Similarly there were no reported cases of cholera in 1989 but 1345 cases were recorded in 1994. The interaction between nutrition and infection is such that poor water quality and sanitation are contributory causes to both growth failure and acute malnutrition requiring hospitalization in children. The lack of capital for repair and updating of the water supply and sewage system is a significant factor associated with both malnutrition and excess infant mortality. The parallel problems of waterlogging and salinity of agricultural land with consequent reduction in the area available for food production should be noted. The causes relating to the inability of purchasing lack of spare parts for pumps and equipment, are identical.
The 1995 Baghdad nutrition and mortality survey of children under-five
years of age, conducted between August 23. to 28., was a collaborative
effort between the FAO Mission and the Nutrition Research Institute (NRI),
part of the Ministry of Health. Mission members were responsible for the
methodology, including the selection of the sample. In the field,
interviews were conducted by NRI staff supervised by FAO Mission members,
a UNICEF member and physicians from the NRI. Data were inputed in Epi-Info
primarily by NRI staff with assistance from Mission members. Once data
entry was completed the data were checked by Mission members and duplicate
records were removed. A total of 693 households were visited and 768
mothers interviewed. Information was collected on 2120 children under 10
years of age. A total of 594 children under-five years of age were
measured for anthropometry, with measurements on 184 children from the
eight clusters in Saddam City that had been surveyed in 1993 by the
previous FAO Mission.
Methods
Selection of clusters for the 1995 Baghdad survey was based upon a random cluster sampling design taken from the nationwide survey of infant and child mortality and nutritional status conducted in 1991. In that survey the number of clusters for each governorate was determined by the population size of the governorate according to the 1987 census. Seventy-three clusters were selected for Baghdad for the 1991 survey. The distribution of clusters within Baghdad was determined by the population size of each district using the 1987 census, representative of the city. Within each district the clusters for the 1995 survey were selected randomly from the 1991 clusters using a random number generator (EPI-INFO, version 6).
The minimum number of clusters required for the 1995 survey was determined to be 25, making the conservative assumption that for 24 contiguous households selected from each cluster between 1-2 children under the age of 10 would be living in each household on average. The assumptions for the sample size for nutritional anthropometry (n = 420) were as follows: a baseline prevalence of wasting of 3.1 % (from 1991 estimates from Baghdad); a 2.5-fold increase in wasting observed in 1995; power of 80%; and an alpha level of .05.
The weight of children between ages 1 and 5 years was ascertained using a calibrated hanging scale to the nearest 0.1 kg. Height was measured to the nearest 0.1 cm, using either a length board (for children under age two) or a height board. Infants under the age of one were measured using an infant scale. Children were measured wearing loose clothing and without shoes. Age was determined primarily through registration cards. Surveyors were from the Nutritional Research Institute (NRI).
Percentiles and Z-scores for height-for-age (stunted), weight-for-age (underweight) and weight-for-height (wasted) were calculated using EPI-Info, version 6. Malnutrition was defined as the percentage of children less than -2 standard deviations (SD) below the median values for the NCHS (United States National Centre for Health Statistics) standardized distributions for the indicators: stunted, underweight and wasted. The criteria for exclusion of observations were:
1. Extreme outlier, defined as values of Z-scores:
a. less than -4 SD or greater than 6 SD for weight-for-height;
b. less than -6 SD or greater than 6 SD for weight-for-age and
height-for-age;
2. Age equal to or greater than 60 months.
Anthropometric indicators (stunted, underweight and wasted) are presented for Baghdad and for the 8 clusters in Saddam City examined in 1993. In addition, anthropometric indicators were stratified for the overall sample by the following characteristics: child age (1 year intervals), maternal education, point prevalence of diarrhoea (defined as 3 loose stools within 24 hours during the past 2 days) and gender. Infant and child mortality estimates are reported comparing pre and post economic sanctions. Effect modification by maternal education in relation to infant and child mortality is also examined.
The percentage of children below -2 SD in the 8 clusters of Saddam City was 25% for stunting, 22% for underweight and 7% for wasting. In the overall sample (25 clusters) for Baghdad, 28% of children were stunted, 29% were underweight and 12% were wasted (Table 26). Severe malnutrition, defined as the percentage of children below -3 SD, was noted among children: 10% for stunted, 7% for underweight and 3% for wasted. Mild malnutrition, the percentage of children below -1 SD, was: 56% for height-for-age, 65% for weight-for-age, and 39% for weight-for-height for the city of Baghdad.
Table 27 presents the prevalence of anthropometric indicators for malnutrition by child age, maternal education and diarrhoeal disease. No significant gender differences were noted in this population. However, certain districts within Baghdad demonstrated higher prevalence estimates of underweight in central part of the city, in neighbourhoods of Rasafah, Karrada and New Baghdad. For wasting higher prevalences were noted in Karkh and New Baqhdad.
Table 28 reports results from the mortality analysis. Infant and child mortality prior to the institution of economic sanctions (August 1990) was compared to the mortality rates for the year prior to the interview (September 1994 to August 1995). Infant mortality had increased approximately two fold compared with the year prior to the intitiation of econonic sanctions. Further analysis indicates a two fold increase in infant mortality during the first year of economic sanctions which included the Gulf War (August 1990 to September 1991). This two fold increase in infant mortality has been sustained since 1990 until the present. Child mortality had increased nearly five fold, comparing the rate prior to the economic sanctions with the rate observed during the past five years. Table 29 stratifies infant and child mortality rates by maternal education. The effect of the sanctions on infant and child mortality is most pronounced among children of illiterate mothers. Infant mortality increased about 3.6 times and child mortality increased 8.5 times compared with pre-sanction estimates for this sub group.
Nutritional status of Iraqi children before the Gulf war and sanctions was similar to children in Kuwait. Since 1991, shortly after the inception of the sanctions, the nutritional status of children in Baghdad has significantly deteriorated. Compared with 1991 estimates, the current survey demonstrates a 4-fold increase in wasting for the city of Baghdad. Prevalence estimates for stunting and underweight have also risen dramatically .
For the Saddam City district of Baghdad, there appears to be a modest reduction in the prevalence of wasting compared with the FAO mission report from 1993 that reported a wasting prevalence of 16 percent. There are several reasons for observed changes in level of wasting which is acutely sensitive to external factors. Since the 1993 survey was conducted in November and the current study was conducted in August, seasonal variation may in part explain the observed reduction in prevalence. Differential child mortality may also explain the lower prevalence of wasting observed in Saddam City in 1995 if severely wasted children were more likely to die in 1995 than in 1993 due to deteriorating conditions. In addition, this population may be better able to cope with adversity since there are more economic options such as begging or peddling goods which were not available in 1993. The Mission noticed that fewer male members were at home during the current survey as compared to the 1993 survey.
For Baghdad overall, the prevalence of underweight children (29%) has increased to a level comparable with children from Ghana (27%) and Mali (31%). For stunting, prevalence rates are similar to estimates from Sri Lanka (28%) and the Congo (27%). The prevalence of wasting in Baghdad is comparable with estimates from Madagascar (12%) and Burma (11%). The prevalence of severe wasting is comparable to data from northern Sudan (2.3%). In contrast, 1991 estimates of malnutrition from Baghdad are comparable with estimates from Kuwait (12% for stunting, 6% for underweight, and 3% for wasting).
The current nutritional situation among children in Baghdad is more
similar to lesser developed countries with a larger percentage of the
population residing in rural settings which may be a reflection of the
inability to maintain systems for sanitation and clean water under
sanctions. The observed increase in under five mortality may also be
related to the sanitation/water problem in Baghdad, where the occurrence
of diarrhoea-related deaths has increased nearly threefold compared to the
time period prior to the sanctions. Due to the increasing problem of food
insecurity and the inability to repair the infrastructure for provision of
sanitation and potable water, the nutritional status of children in
Baghdad will continue to deteriorate unless appropriate measures are taken
to secure food and to provide a safe environment. The Mission recommends
that a nationwide nutritional surveillance system be put into place
immediately in light of the poor nutritonal status and mortality of
children under five years of age in Iraq. Moreover, should be noted that
the nutritional status of children in southern Iraq and North is likely to
be even worse than reported in Baghdad.
The situation throughout the country is increasingly disastrous with economic decline spreading across almost all sectors of Iraqi society. Of particular concern to the Mission is the ability of the country to feed itself and to provide a quality system of health care. Malnutrition is widespread affecting nearly all social groups throughout the country with as many as 12% of children surveyed in Baghdad wasted and 28% stunted. If no action is taken the nutritional situation will undoubtedly get worse, and rates of child mortality will increase.
Despite the complexity of the problems, both the cause and the solution are, in principle, clear. Without hard currency the country cannot purchase food, medicines, spare parts, machinery, fertilizers, seeds, herbicides and other agricultural inputs. The reduction in imports combined with the resultant decline in agricultural production has led to a serious reduction in the amount and quality of foods available for consumption by the population. This reduction in availability is aggravated by hyperinflation (also caused by the inability to generate foreign exchange), as many families do not have sufficient money to purchase the food which is available in the market place. In a parallel manner, without spare parts for pumps and other needed material for the water supply and sewage disposal system, impure water and sewage backups produce severe health risks for the population. The combination of decreased food availability and the occurrence of infectious disease results in increasing malnutrition especially in children.
Although the Security Council Resolutions permit the importation of food, health and other basic necessities from Iraqi frozen assets, insufficient funds from these assets have been released for humanitarian purposes. As a consequence the amount of food required and the supplies needed to produce and process food have been far in excess of the amounts the GOI has been able to import with its limited foreign exchange. Further, although the resumption of sales of oil has been extensively discussed, the embargo on such sales has not yet been lifted. It is unlikely at the present time that the donor community will come forward with the resources needed to make up for the shortfall and in view of the deteriorating nutrition and health situation throughout the country the reduction in aid is a matter of grave concern. If this situation is allowed to continue the result will undoubtedly be even further deterioration in the nutritional status and health of large sections of the Iraqi population. There is a strong possibility of an outright collapse of the food and agricultural economy which would cripple the food ration system and lead to widespread famine and hunger.
A. Food Production and Access
B. Nutritional Status
Because of the increasing cost of food and decreasing purchasing power, the ability to secure a balanced diet is increasingly unavailable to the vast majority of the population and nutritional status continues to go from bad to worse. If no additional funds or resources are provided the Mission recommends that the following steps should be taken:
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Crop 1990 1991 1992 1993 1994 1995
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Wheat 1,196 2,517 1,677 2,013 1,806 1,535
Barley 1,995 2,412 2,012 2,314 1,535 1,389
Paddy 79 86 95 110 163 175
Maize 77 118 141 160 70 75
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Total 3,347 5,133 3,925 4,597 3,574 3,174
----------------------------------------------------------------------
----------------------------------------------------------------------
Crop 1990 1991 1992 1993 1994 1995
----------------------------------------------------------------------
Wheat 1,196 1,477 1,006 1,187 1,342 1,236
Barley 1,854 768 1,509 1,562 971 892
Paddy 228 189 180 206 383 315
Maize 173 236 260 280 128 90
----------------------------------------------------------------------
Total 3,451 2,670 2,955 3,235 2,824 2,533
----------------------------------------------------------------------
----------------------------------------------------------------------
Crop 1990 1991 1992 1993 1994 1995
----------------------------------------------------------------------
Wheat 1,000 586 600 590 743 805
Barley 929 318 750 675 633 642
Paddy 2,886 2,198 1,137 1,124 2,350 1,800
Maize 2,247 2,000 1,844 1,750 1,829 1,200
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Total 1,031 520 753 704 793 798
----------------------------------------------------------------------
----------------------------------------------------------------------
1995
Crop -----------------------------------------------------------
Area Production Yield
('000 Ha) ('000 Tons) (kg/ha)
----------------------------------------------------------------------
Wheat 1,000 798 798
Barley 1,250 790 632
Paddy 175 315 1,800
Maize 75 90 1,200
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Total 2,500 1,993 773
----------------------------------------------------------------------
----------------------------------------------------------------------
1995
Crop -----------------------------------------------------------
Area Production Yield
('000 ha) ('000 tons} (kg/ha)
----------------------------------------------------------------------
Wheat 535 438 819
Barley 139 102 734
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Total 674 540 801
----------------------------------------------------------------------
----------------------------------------------------------------------
Years
Crops -----------------------------------------------------------
1989 1991 1994 May 1995
----------------------------------------------------------------------
1. Wheat
----------------------------------------------------------------------
Class 1 270 800 35,000 105,000
Coarse Wheat 251 800 34,000 100,000
Other Varieties 220 700 33,000 95,000
----------------------------------------------------------------------
2. Barley
----------------------------------------------------------------------
Barley 180 500 20,000 60,000
----------------------------------------------------------------------
3. Rice (Paddy}
----------------------------------------------------------------------
Anbar & Nakaza 500 1,700 75,000 150,000
Meshkab 400 1,200 65,000 130,000
Other Varieties - 1,700 60,000 120,000
----------------------------------------------------------------------
4. Maize
----------------------------------------------------------------------
Grains 550 700 17,000 75,000
Corn Ears 400 510 15,000 65,000
----------------------------------------------------------------------
5. Sunflower 1,000 1,500 35,000 35,000
----------------------------------------------------------------------
----------------------------------------------------------------------
Year 1989 1990 1991 1992 1993 1994 1995
----------------------------------------------------------------------
Number of orchards 84,000
(all types)
----------------------------------------------------------------------
Production (000 tons) 958 1,10 1,19 1,19 1,26 1,27 1,300
2 4 5 7 0
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Source: Annual Abstract of Statistics, Ministry of Planning, different years; and mission estimate for 1995 based on information from different sources.
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Year 1991 1992 1993 1994 1995
----------------------------------------------------------------------
Total number of date 16 - 18 million
palm trees
Production (OOOtons) 566 447 612 650 650-700
----------------------------------------------------------------------
Source: Annual Abstract of Statistics, Ministry of Planning,
different years; and mission estimates.
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Animal 1990 1993 1995
----------------------------------------------------------------------
Cows 1,512,000 1,120,000 1,000,000
Buffaloes 129,000 98,700 70,000
Sheep 8,631,000 6,300,000 5,000,000
Goats 1,315,000 1,050,000 250,000
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Source: The international Scientific symposium on post war
environmental problems in Iraq, December 10-12, 1994. The figures
for 1995 are mission and Government estimates.
----------------------------------------------------------------------
Per Capita Share
--------------------------------------------------------
Products Before the Gulf After the Gulf War
--------------------------------------------------------
1990 1993 1995
----------------------------------------------------------------------
1. Milk (Kg/year) 15 3.5 2
2. Table eggs (Eggs/year) 85 25 10
3. Red Meat (Kg/year) 13 2.8 1.5
4. Chicken meat (Kg/year) 12.5 1.5 1.0
5. Fish (Kg/year) 3.5 1.5 1.0
6. Animal Proteins 18 5 2
----------------------------------------------------------------------
Source: The International Scientific Symposium on Post War
Environmental Problems in Iraq, Baghdad, December 10-12, 1994.
Data for 1995 are Mission and Government estimates.
----------------------------------------------------------------------
Estimated (a) Total Shortage or Shortage as
Commodity Production Requirement (b) Import % of Total
('000 tons) ('000 tons) Requirement Requirement
----------------------------------------------------------------------
Wheat flour 989 3,209 2,220 69
Rice 221 994 773 78
Barley 892 1,217 327 27
Maize. 9O 213 123 (c) 58
Pulses (d) 50 120 70 58
Vegetable oil 100 298 198 66
Red Meat 94 227 133 58
Poultry meat 20 227 207 90
Fish 5 62 57 92
Eggs (million) 150 1,966 1,816 92
Milk N.A. 372 223 (e) 93
Tea none 62 62 100
Sugar 80 814 734 90
Baby Milk (for negligible 43 43 100
children under
one year)
----------------------------------------------------------------------
(a) Government and mission estimates. Conversion ratio of wheat into flour is 80 per cent, reflecting the high rate of non-grain impurities in the 1995 wheat output; the recovery rate in the case of paddy into rice is 70 per cent.
(b) Calculated using standard per person annual requirement of each item in Iraq.
(c) If maize for feed for poultry and livestock is included, the quantity will be much larger.
(d) Include peas, green grain, lentil, broad beans, beans.
(e) Milk production in the country has declined sharply. It has been generously assumed that some 40 per cent of the requirement will be met through domestic production of fresh milk or that many poor people may not consume milk.
N.A. = not available.
Note: Total population 1995/1996: 20.7 million.
----------------------------------------------------------------------
Commodity 1993 1995
Since 24
September 1994
----------------------------------------------------------------------
Grain flour 9.000 6.000
Rice 2.250 1.250
Vegetable oil 0.500 0.625
Sugar 1.500 0.500
Tea 0.075 0.100
Baby milk + 1.800 1.800
----------------------------------------------------------------------
K/cal value per 1,654 1,093
capita per day
excluding baby
milk
----------------------------------------------------------------------
as % of 1987 - 53% 34%
1989, average
calorie availability
----------------------------------------------------------------------
+ Baby milk is provided for infants 0-1 years (four tins weighing 450 grams each for each infant). The estimated number of infants in Iraq is 1 million, of whom 0.826 million in Central and south Iraq. The quantity provided meets about 50 per cent of the baby's need.
----------------------------------------------------------------------
Quantity Ration Value at Value at Implicit
Supplied Price Ration Market Price Monthly
Commodity per Person ID/kg Price (ID) August 1995 Subsidy
kg/month (ID} (ID)
----------------------------------------------------------------------
Wheat flour 6.000 0.690 4.140 4,800 4,796
Rice 1.250 0.300 0.375 1,250 1,249
Vegetable oil 0.625 0.640 0.634 1,688 1,687
Sugar 0.500 0.200 0.100 550 550
Tea 0.100 2.000 0.200 300 300
Baby milk 1.800 1.667 3.000 16,020 16,017
----------------------------------------------------------------------
Total per 9.589 8,588 8,579
person/month
excluding baby
under one year
----------------------------------------------------------------------
Full ration basket 47.945 42,940 42,895
for the family (5
members) excluding
baby under one year
----------------------------------------------------------------------
Full ration basket for a 50.945 58,960 58,912
family of six including
one child under one
year
----------------------------------------------------------------------
----------------------------------------------------------------------
Monthly Annual Total Annual Annual Production
Per Per Requirement Requirement ('000 tons)
Capita Capita for Iraq for Central 1994/95
Item Ration Ration (population and South --------------
(kg) (kg) 20.7 million of Iraq Whole Central
minus one (population Iraq and
million 17.1 million South
children under minus
one year) 0.826 million
('000 tons) children under
one year)
('000 tons)
----------------------------------------------------------------------
Wheat
flour 6.000 72 1,490.4 1,171.7 989 638
Rice 1.250 15 310.5 256.5 221 221
Sugar 0.500 6 124.2 102.6 80 72
Tea 0.100 1.2 24.8 20.5 none none
Vegetable
oil 0.625 7.5 155.3 128.3 100 75
Baby
milk 1.800 21.6 21.6 17.8 negligible
(powder) negligible
----------------------------------------------------------------------
Note: Recovery rate used for wheat is 85% and for paddy 70%.
----------------------------------------------------------------------
End Increase in Increase in Increase
July June August June 1993 August 1995 in August
Food 1990 1993 1995 over July over July 1995 over
Item ID/kg ID/kg ID/kg 1990 Prices 1990 Prices June 1993
(times) (times) (times)
----------------------------------------------------------------------
Wheat
flour 0.060 21.273 700 355 11,667 33
Rice 0.240 17.090 1,000 71 4,767 58
Vegetable
oil 0.600 63.545 2,700 106 4,500 43
Cheese
(local) 1.600 64.727 2,000 40 1,250 31
Fish 5.000 56.909 1,200 11 240 21
Milk
powder 1.600 129.854 7,000 81 4,375 54
Lentils 0.400 29.055 800 73 2,000 28
Potatoes 0.500 12.143 750 24 1,500 62
Sugar 0.200 29.727 1,100 149 5,500 37
Tea 2.000 192.818 3,000 96 1,500 16
Red meat 7.756 90.360 1,500 12 193 17
Poultry
meat 3.000 68.286 2,500 23 833 37
Eggs (30
eggs) 3.600 80.011 4,000 22 1,111 50
Baby
milk 1.600 532.000 8,900 332 5,562 17
----------------------------------------------------------------------
----------------------------------------------------------------------
Shortage or Unit price (a) Import Cost
Import (CIF Baghdad) Million US $
Commodity Requirement US $ per ton
('000 tons)
----------------------------------------------------------------------
Wheat flour 2,220 224 497
Rice 773 370 286
Coarse grains 450 190 86
Pulses 70 750 53
Vegetable oil 198 1,000 198
Red meat 133 2,200 293
Poultry meat 207 950 197
Eggs (million) 1,816 18 (per box of 91
360 eggs)
Milk 223 2,100 468
Tea 62 1,500 93
Sugar 734 500 367
Baby milk (for
children under
one year) 43 3,000 129
----------------------------------------------------------------------
Total import 2,758
requirement
---------------------------------------------------------------------
(a) Collected from importers in the two main wholesale markets in Baghdad City - Shorja and Jamila.
----------------------------------------------------------------------
Daily Supply
-------------------------------------
Requir. Requir. % cov. of % cov. of
Nutrient 0-6 m 6m-1 year Value req. 0-6m reqy. 6m-1
year
----------------------------------------------------------------------
Food energy
(kcal) 650 850 317 49 37
Protein (gm) 13 14 7 54 50
Calcium (mg) 400 600 200 50 33
Zinc (mg) 5 5 3 60 60
Vitamin A
(yg RE) 375 375 286 76 76
Vitamin C
(mg) 30 35 27 90 77
Thiamine
(yg) 300 400 317 106 79
Folic
acid (yg) 25 35 24 96 68
Iron (mg) 6 10 1 17 10
----------------------------------------------------------------------
Notes: Ration supply of baby food can vary both by product variety and manufacturer. Most standard formulations are broadly similar in composition. Values are calculated using average nutrient values for several products. Requirement for children from RDA's for the USA (NAS-NRC 1989).
----------------------------------------------------------------------
Daily Ration
FBS (a) Adult --------------------------------
Mutrient 1988/90 RDA (b) Value % cov. FBS % cov. RDA
----------------------------------------------------------------------
Food energy
(kcal) 3120 2900 1093 35 38
Protein (gm) 82.5 63.0 26.9 33 43
Fat (g) . 75.3 - 22 29 -
Calcium (mg) 467 800 79 17 10
Iron (mg) 26.0 10 8.2 32 82
Zinc (mg) 17.3 15 6.7 39 45
Vitamin A
(yg RE) 1332 1000 1.2 0 0
Vitamin C (mg) 728.0 60 0 0 0
Thiamine (mg) 3.2 1.5 1.2 38 75
Riboflavin (mg) 1.7 1.7 0.5 29 29
Folate (yg) 352 200 80 23 40
Vitamin B6 (mg) 2.6 2.0 0.9 35 45
Lysine (mg/g pro.) 47 58 32 68 55
----------------------------------------------------------------------
(a) Food balance sheet.
(b) Recommended daily allowance.
Note: RDA values (NAS-NRC 1989): adult male 25-50 years. Lysine mg/g protein is indicative of protein quality. This is not an RDA but is the value recommended by FAO/WH0 1991.
----------------------------------------------------------------------
Year Kwashiorkor Marasmus Other Malnutrition
----------------------------------------------------------------------
1990 41 433 8,063
1991 1,066 8,015 78,990
1992 1,145 9,289 93,610
1993 1,261 11,612 102,971
1994 1,748 16,025 131,349
1995 (a) 2,237 20,549 140,354
----------------------------------------------------------------------
(a) January to July
Source: Government of Iraq, Vital and Health Statistics Department.
----------------------------------------------------------------------
Year Period Total Deaths Monthly Average
----------------------------------------------------------------------
1989 Jan - Dec 7,110 593
1990 Aug - Dec 8,903 1,483
1991 Jan - Dec 27,473 2,289
1992 Jan - Dec 46,933 3,911
1993 Jan - Dec 49,762 4,147
1994 Jan - Dec 52,905 4,409
1995 Jan - Jul 31,327 4,475
----------------------------------------------------------------------
(a) Selected causes include respiratory infections, diarrhoea/ gastroenteritis, and malnutrition.
Source: Government of Iraq, Vital and Health Statistics Department.
----------------------------------------------------------------------
Total No.
Paediatric Patients Percent of Total Deaths
------------------- No. of Diarrhoeal No. of Due to
1994 1995 Diarrhoeal Cases from Deaths Diarrh.
Months Cases Total of
Paediatric
Patients
----------------------------------------------------------------------
January 481 505 211 41.8 12 1
February 409 530 208 39.2 35 0
March 309 546 125 22.9 29 3
April 282 490 109 20.2 18 3
May 376 557 435 78.1 34 3
June - 607 554 91.3 27 6
----------------------------------------------------------------------
Source: Statistical Department, Mosul Saddam Hospital
----------------------------------------------------------------------
Month Total Birth % EBW
----------------------------------------------------------------------
January 265 4.2
February 341 3.8
March 388 2.8
April 354 2.5
May 297 3.4
June 306 1.0
July 367 2.7
Average 363 3.7
----------------------------------------------------------------------
Source: Statistical Department, Mosul Saddam Hospital
----------------------------------------------------------------------
Name of Health April May June August September October
Centre r
----------------------------------------------------------------------
Ainkawa 59 79 79 106 201 209
Daratoo 201 - 195 - - -
Badawa 142 224 253 156 140 -
M. Baiellan 932 500 500 500 500 500
Beneselawa 185 185 - 215 220 220
Terawa 246 226 300 337 341 34
----------------------------------------------------------------------
Totals 1765 1214 1327 1394 1402 1270
----------------------------------------------------------------------
r not reported
Note: July not reported
Source: Miller, Cathy. Impact Teams International
----------------------------------------------------------------------
% Marasmus
Total Total No. of Malnutrition (weight/height)
Date Paediatric Malmutrition Cases to ---------------------
Admissions Admissions Total Severe % of Total
Admissions Cases Malnutrition
(<70%)
----------------------------------------------------------------------
1993
Jan. 1,820 78 4.3 16 20.5
June 3,385 65 1.9 17 26.2
July 4,086 122 3.0 30 24.6
Dec. 1,847 138 7.5 33 23.9
1994
Jan. 2,104 108 5.1 35 32.4
June 3,109 326 10.5 84 25.8
July 3,286 606 18.4 195 32.2
Dec. 1,303 234 17.9 78 33.3
1995
Jan. 1,240 362 29.2 97 26.8
June 2,903 592 20.4 188 31.8
July 2,369 502 21.2 177 35.3
----------------------------------------------------------------------
----------------------------------------------------------------------
Marasmus
(weight/height) Kwashiorkor Number
Date -------------------------------------------- Cases of
Moderate % of Total Mild % of Total Deaths
Cases Malnutri. Cases Malnutri.
(70- 80%) (80-85%)
----------------------------------------------------------------------
1993
Jan. 14 18.0 30 38.5 18 3
June 13 20.0 25 38.5 10 -
July 23 18.9 52 42.6 17 -
Dec. 18 13.0 50 36.2 37 -
1994
Jan. 13 12.0 47 43.5 13 -
June 66 20.2 149 45.7 27 18
July 94 15.5 290 47.9 27 10
Dec. 37 15.8 106 45.3 13 4
1995
Jan. 79 26.8 170 47.0 16 2
June 106 17.9 293 49.5 5 6
July 75 42.4 298 49.4 2 14
----------------------------------------------------------------------
Source Suleimaniya Paediatric Hospital
----------------------------------------------------------------------
Month No. of No. of No. of No. of Case
1994 Children Children Prevalence Children Children Fatality
Admitted with GE Rate Who Died Died Due Rate
to GE
----------------------------------------------------------------------
Jan. 913 225 24.6 78 12 15.4
Febr. 757 128 16.9 76 12 15.7
March 512 91 17.8 45 7 15.5
April 649 184 28.4 46 11 23.9
May 654 294 45.0 49 16 32.7
June 1278 850 66.5 71 37 52.1
July 848 527 62.1 60 29 48.3
Aug. 952 542 57.0 36 12 33.3
Sept. 1040 578 55.6 43 11 25.6
Oct. 918 506 55.1 52 24 46.1
Nov. 852 410 48.1 61 27 44.3
Dec. 792 351 44.3 57 24 42.1
----------------------------------------------------------------------
Total 10165 4686 46.1 674 222 32.9
----------------------------------------------------------------------
Source: Miller. Cathy. Impact Teams International
----------------------------------------------------------------------
Saddam City Baghdad
Anthropometric --------------------------------------------------
Indicator 1993 (a) 1995 (b) 1991 (c) 1995 (d)
n = 194 n = 184 n = 520 n = 594
----------------------------------------------------------------------
% < -2 SD Z-score 30% 25% 12% 28%
height for age
% < -2 SD Z-score 35% 22% 7% 29%
weight for age
% < -2 SD Z-score 16% 7% 3% 12%
weight for height
----------------------------------------------------------------------
(a) Data from the FAO report of the Nutritional Status Assessment Mission to Iraq, November 19
(b) Data collected from the same area included in the FAO 1993 assessment, current report (199
(c) Data from the International Study Team for the city of Baghdad, August-September 1991.
(d) Data from random selection of 25 clusters/neighbourhoods in Baghdad, current report (1995)
----------------------------------------------------------------------
Per Cent Below-2 SD (Z-score)
Demographic ----------------------------------------------------
Characteristic Height for Age Weight for Age Weight for Height
----------------------------------------------------------------------
Age (months) (n = 585) (n = 593) (n = 588)
0 - 11 23% 25% 13%
12 - 23 38% 35% 12%
24 - 35 26% 35% 13%
36 - 47 30% 24% 5%
48 - 59 24% 25% 17%
----------------------------------------------------------------------
Maternal education (n = 585) (n = 593) (n = 588)
Illiterate 32% 36% 16%
Primary 35% 28% 9%
Secondary 21% 29% 14%
Post-secondary 16% 24% 13%
----------------------------------------------------------------------
Diarrhoeal
disease (a) (n = 576) (n = 584) (n = 579)
Yes 26% 31% 16%
No 29% 29% 11 %
----------------------------------------------------------------------
(a) Diarrhoeal disease is defined as 3 loose stools within 24 hours during the past 2 days.
----------------------------------------------------------------------
Age Group Reference Period During Economic Relative Mortality
(1) Sanctions (2) (95% confidence
interval)
----------------------------------------------------------------------
Infant Mortaiity
(< 1 year of age)
No. of deaths 16 36 2.0
No. of live births 199 224 (1.15, 3.49)
Risk of infant death .0804 .1607
----------------------------------------------------------------------
Child Mortality
( < 5 years of age)
No. of deaths 33 245 4.88
No. of children born 812 1,236 (3.43, 6.94)
Risk of child death .0406 .1982
----------------------------------------------------------------------
1. Reference period for infant mortality includes all children born between August 1989 and July 1990. Reference period for child mortality includes all children born between August 1985 and July 1990.
2. Index period (during economic sanctions) for infant mortality includes all children born in the year prior to the date of interview (September 1994 to August 1995). Index period for calculation of child mortality includes all children born from August 1990 to the date of interview (under the age of 5).
----------------------------------------------------------------------
Reference During Relative Mortality
Age Group Period (1) Economic (95% confidence
Sanctions (2) interval)
---------------------------
Mortality Rate
----------------------------------------------------------------------
Infant Mortality
( < 1 year of age)
Maternal education ,
Illiterate .077 .256 3.59 (1.07, 12.09)
Primary .084 .143 1.70 (.78, 3.71)
Second/Post-Sec. .076 .138 1.82 (.61, 5.42)
----------------------------------------------------------------------
Child Mortality
( < 5 years of age)
Maternal education
Illiterate .034 .289 8.50 (3.99, 18.07)
Primary .042 .186 4.44 (2,67, 7.40)
Second/Post-Sec. .045 .164 3.67 (1.93, 6.98)
----------------------------------------------------------------------
1. Reference period for infant mortality includes all children born between August 1989 and July 1990. Reference period for child mortality includes all children born between August 1985 and July 1990.
2. Index period (during economic sanctions) for infant mortality
includes all children born in the year prior to the date of
interview (September 1994 to August 1995). Index period for
calculation of child mortality includes all children born from
August 1990 to the date of interview (under the age of 5).