Indian Journal of Medical Ethics

EDITORIAL

Who speaks for the children of Iraq?

ZULFIQAR AHMED BHUTTA

'What difference does it make to the dead, the orphans and the homeless, whether the mad destruction is wrought under the name of totalitarianism or the holy name of liberty or democracy?' Non-violence in peace and war

-Mahatma Gandhi (1869-1948)

Another war in Iraq is sadly under way and in these early days, it is already apparent that the hopes of a short surgical conflict a.k.a. Kosovo or a blitzkrieg like the last Gulf war, were wildly misplaced. Those expecting the Iraqi military and the populace to rapidly capitulate in the face of 'shock and awe' tactics of massive air-strikes, are 'surprised' by the resilience of an opposition facing certain defeat. To others who remember the tenacity of the people of Viet Nam and Afghanistan, this is hardly surprising and portends a long bruising campaign ahead. In any event, unprecedented dust storms in the region and steadily growing list of civilian casualties serve to remind us that despite modern technology, war is indeed a dirty affair. The sad fact remains that global superpowers have yet again chosen to spend billions on destroying infrastructure and lives for gains that are both debatable and unpredictable.

It is not the purpose of this article to debate the genesis of the Iraq conflict, nor the issue of whether a ruthless tyrant like Saddam Hussain deserves any slack. The issue in question is whether the end justifies the means and if it is ethical to impose such a price on a nation that has suffered long at the hand of a brutal domestic regime and global sanctions. Even though one may not have witnessed human suffering as a direct result of conflict and war injuries, such as that witnessed in Afghanistan (1), the impact of sanctions on child health and mortality is staggering (2). UNICEF estimates indicate that 'if the substantial reduction in child mortality throughout Iraq during the 1980s had continued through the 1990s, there would have been half a million fewer deaths of children under-5 in the country as a whole during the eight-year period 1991 to 1998' (3).

The land of Iraq, or Mesopotamia of old, is no stranger to conflict and brutality. The simmering strife and conflicts between successive generations of Assyrians, Greeks and Suljuks paled in comparison to the savage destruction of Baghdad by the Mongols in 1258. The Mongols not only destroyed all forms of art and culture and scholarship in Iraq, but also the canal head works, leading to the relegation of Iraq to economic wasteland for almost six centuries. It is interesting to note that the British were the first among the western states to invade Iraq in 1914 to protect their interest against the perceived pro-German policies of the Ottoman Empire. The decades of conflict that followed eventually saw the emergence of Iraq as a sovereign state in 1932 followed by the first military coup of the modern Arab world in 1936. The subsequent emergence of the Baath party posed a direct challenge to the monarchy and the promotion of pan-Arabism. The emergence of Ahmad Hasan al Bakr and eventually Saddam Hussain by early 1979, followed a series of brutal internal conflicts with the Kurds as well a series of border disputes with Iran and Kuwait (4). The outbreak of the Iran-Iraq war in September 1980 led to unprecedented loss of life and property and severe economic misery for the people of Iran and Iraq. Saddam Hussain's reprehensible decision to invade Iran was akin to the acts of the ancient rulers of Mesopotamia who, fearing internal strife and foreign conquest, also engaged in frequent battles with the peoples of the highlands. The folly of the invasion of Iran by Saddam pales in the wake of the invasion of Kuwait in 1989 and the consequences of the Gulf War that followed. It is highly debatable if the common man in the street in Iraq has had any meaningful input in the affairs of the state. As reprehensible as it may be, the current Iraqi regime, and the weaponry it possesses, is a direct product of vested interests by western powers. When confronted with the choice during the Iran-Iraq war, most western states blatantly supported Saddam Hussain and steadily poured in military technology and hardware. Even the horrors of chemical and possibly biological warfare perpetrated by Saddam Hussain were conveniently ignored. It is only when 'the devil of their own creation' turned upon Kuwait with the consequent threat to global oil supplies that the West woke up to confront Saddam. However, in an interesting choice of tactics, once faced with the choice of eliminating Saddam and his government after a clear military victory, the military command led by General Colin Powell chose not to do so. Instead, a draconian and incomprehensible decade of economic sanctions followed, which hit the most vulnerable in Iraqi society, especially its women and children. To illustrate, immediately following the Gulf war it was estimated that under-5 mortality in Iraq had increased three-fold (5) and subsequently the rates of malnutrition were estimated to have doubled (6).

Today as the world once again sets upon to impose war on the region, precious little thought is being given to the collateral effects and consequences of war. In a series of assessments Medact estimates that the number of casualties during and immediately following the invasion of Iraq could range from 48,000-260,000, with an estimated 200,000 deaths from post-war adverse effects due to a breakdown of the health system (7). Despite the widespread claims of a short, sharp decisive conflict, an internal confidential document by the United Nations predicts several hundred thousand deaths and a health and nutritional crisis of epidemic proportions (8). In the words of Jean Paul-Sartre (1905-80), 'when the rich wage war, it's the poor who die'. In an increasingly unipolar world, none of these issues, or the likely regional and global political fallout of the Iraq war, seem to be making much headway. The protests by the millions marching in the streets of Europe and Asia are rejected out of hand, while blatant and unethical attempts at economic coercion and political blackmail to swing the vote in the Security Council continue unabated. Few realize that while the perpetrators of the Iraq war might achieve their short-term goals of regime change, few have the stomach to oversee long-term development objectives and the region may be left to fend for itself. It is sobering to note that the same powers that spent over US$ 10 billion on dislodging the Taliban in Afghanistan, have not been able to fulfil even a third of the promised commitments for economic assistance to the country. Today the world is again poised to spend over US$ 85 billion on the most expensive war of the new millennium, yet the Global Fund languishes for a fraction of the funds and the floundering global maternal and child health intervention programmes can be rejuvenated for a fiftieth of the amount! Not to protest against this madness would be unconscionable. To offer war as the only solution to 'help' the people of Iraq is an affront to justice and humanity.

References
1. Bhutta ZA. Children of war: the real casualties of the Afghan conflict. BMJ 2002;324:349-52.
2. Ali MM, Shah IH. Sanctions and childhood mortality in Iraq. Lancet 2000;355:1851-7.
3. UNICEF Statement. UNICEF, August 12, 1999.
4. Khadduri M. The role of the military in Iraqi society. In: Fisher SN (ed). The military in the Middle East. Columbus: Ohio State University Press, 1963:41-51.
5. Ascherio A, Chase R, Cote T, Dehaes G, Hoskins E, Laaouej J, et al. Effect of the Gulf war on infant and child mortality in Iraq. N Engl J Med 1992;327:931-6.
6. Central Statistical Organisations. The 1996 multiple indicators cluster survey: a survey to assess the situation of children and women in Iraq. Final Report with results from the south-centre governorates. Baghdad: UNICEF, 1997 (UNICEF IRQ/97/288).
7. Medact. Collateral damage: The health and environmental costs of war on Iraq. [http://www.medact.org]
8. United Nations. Likely humanitarian scenarios. Available from the Campaign Against Sanctions on Iraq [http://www.cam.ac.uk/societies/casi]
9. White F. Can international public health law help to prevent war? Bull WHO 2003;81:228.

ZULFIQAR AHMED BHUTTA

The Husein Lalji Dewraj Professor, The Aga Khan University, Karachi (Pakistan). e-mail:zulfiqar.bhutta@aku.edu