Throughout the 1990s, social conditions in Iraq have deteriorated to levels last experienced three and four decades ago. This decline is associated with a dramatic reduction of the gross national product from around $3,500 to under $700 per capita, but changes in the GNP do not tell the entire story.  While Iraq’s social indicators, including child mortality, today are certainly not the lowest in the world, the extent and rate of decline there is unprecedented in the modern world.
Not all embargoes have been implemented with equivalent thoroughness, and even under the strictest embargoes some goods get through. Yet many embargoes bring increased social costs and disruption that are not entirely mitigated by humanitarian aid. The embargoes with the greatest impact on the health of the general population are those that are multilateral and comprehensive, occur in countries with heavy import dependence, are implemented rapidly and are accompanied by other economic and social blows to a country. Iraq shares each of these characteristics. Cuba shares them to a more limited extent, but its response in terms of protecting the most vulnerable sectors of the population provides an instructive contrast to that of Iraq.
The impact of sanctions on public health is not limited to problems with the supply of medicines. Health and health services depend on functioning water and sanitation infrastructure, and on electricity to run that infrastructure, as well as X-ray and other diagnostic facilities and refrigerators to store vaccines. Humanitarian exemptions for food and medicines are necessary but insufficient to maintain health. Health infrastructure deteriorates not only due to a lack of imports but also due to a reduction in a government’s capacity to provide capital investment, and cover maintenance and operating costs. As services decline, people are less inclined to use them, coping with the impact of sanctions on their livelihoods in alternative ways.
Claims of a million-plus deaths of Iraqi children due to economic sanctions are based on Iraqi Ministry of Health information provided since 1993 on the number of deaths recorded in hospitals. Among children under five years of age, all deaths due to respiratory infections, diarrhea. gastroenteritis and malnutrition are counted as deaths caused by sanctions. Among those over five years of age, all deaths due to cardiac diseases, hypertension, diabetes mellitus, renal diseases, liver diseases and cancers are counted as caused by sanctions. There are serious methodological problems with this mortality data. First, not all the deaths from these causes are related to sanctions. Cancer and heart diseases, for example, were the most common causes of death among adults prior to the Gulf war. “Diagnostic drift,” an assumption that sanctions are causing the deaths, may increase the number of deaths recorded as such. On the other hand, many deaths that occur outside of hospitals are not included in these data. In 1989, for example, only about a third of all estimated deaths among under five-year-olds were registered in hospitals. As a result of the embargo, many people no longer went to hospitals, or went for only brief periods. Finding no treatments, they returned home to die in far greater numbers than before sanctions were imposed. Moreover, many hospital-based deaths are listed under unknown causes due to the lack of adequate diagnostic and laboratory equipment. Most hospital data systems are in disarray, with clinical notes written on odd scraps of paper or old charts of other patients.  Most hospital statistical offices no longer generate routine reports and few of their computers still work. Though the Oil-for-Food program began to resupply the system in 1998, little improvement has resulted, and many hospital-based deaths still go unrecorded or misdiagnosed. For all of these reasons, the deaths recorded by the government of Iraq provide unreliable estimates of changes in death rates.
A demographic survey run by UNICEF in 1999 provides the first reliable mortality estimates for Iraq since 1991. This study confirmed that the rate of mortality more than doubled (from 56 per 1,000 births during 1984-89) among children under five years in the fifteen governorates of central/southern Iraq, to 131 per 1000 births, during 1995-99.  A short-term rise in deaths occurred during the initial embargo in 1990. Diarrhea and war-related mortality rose steeply during and following the Gulf war and postwar insurrections in early 1991. Starting in 1991, decreased access to food and increased risk of respiratory and diarrheal infections led to a marked increase in malnutrition among those reaching twelve months of age, when the protections offered by breast-feeding wane and risks from poor weaning practices rise.
Those unprotected by breast-feeding were at far greater risk. Although the prevalence of breast-feeding was high, bottle-feeding has increased since 1997, when the government put infant formula on the ration against the advice of UNICEF and other international organizations. Even before that, few infants were exclusively breast-fed during the first six months, and the introduction of complementary semisolid foods failed to reach a third of children aged six to nine months. Malnutrition among women giving birth led to a high rate of low-weight births and high mortality within the first weeks of life. Without significant improvements in sanitation, food sources, or medical care, many of the children with acute malnutrition after weaning became chronically malnourished as toddlers. They were at increased risk of serious disease and death, especially from measles, diarrhea and respiratory infections.
Throughout Iraq, grain and meat production fell, purchasing power and educational achievement declined, and the energy, water, medical and transportation infrastructure deteriorated. These changes left all Iraqis’ health at greater risk, especially girls, the poor, inhabitants of rural areas or the southern governorates, and others with more limited access to education, goods, services and infrastructure.
Declining fertility, along with sharply increased mortality among under five-year-olds, accounts for a fall in the proportion of the population under age fifteen from 46 percent in 1987 to 40 percent in 1997. Increased mortality and emigration among those above 65 years of age has similarly reduced this group from 5 percent of the population in 1977 to 3.2 percent in 1999.  The doubling of death rates among under five-year-olds, the decline in marriages and the other demographic changes noted above are unprecedented. A conservative estimate of “excess deaths” among children under five since 1991 would be 300,000. While this number is far less than that claimed by the Iraqi government, it confirms that a grave and sustained rise in the preventable deaths of children under five has occurred in Iraq. This lower estimate, incidentally, is still far more than the high estimate of 56,000 fatalities that occurred in the Gulf war itself. Moreover, UNICEF’s mortality rate findings represent only the tip of the iceberg as to the enormous damage done to the four out of five Iraqis who do survive beyond their fifth birthday.
Changes in Living Conditions
For instance, primary school enrollment declined from 98 percent of all children above 6 years of age in 1988-90 to 88 percent for males and 80 percent for females in the government-controlled center/south during 1997-98.  The percentage of children failing to graduate from primary school reportedly rose from 17 during 1991-92 to 40 in 1993-94. This decline in schooling over a decade has helped literacy decline from 80 percent of the adult population in 1987 to 58 percent in 1995.
Registered marriages dropped from 170,000 in 1989 to 121,000 in 1995 and completed fertility among married women declined from an average of eight to seven children.
During 1991-96, average calorie availability from all sources declined about a third, from 3,500 to 2,300. Calories available through the government-distributed ration fell from 1,770 in 1993 to 1,130 in 1994 and rose to about 2,000 in 1998.  Maldistribution of foods within families and generalized shortages of protein, vitamin A, iron and iodine resulted in malnutrition among a third of all children under age five. By 1996, improved access to food and other services in the northern autonomous region controlled by the Kurdish parties produced a slight decline in both chronic and acute malnutrition to 26.3 percent and 3.8 percent, respectively) while embargo-related shortages led to a rise of both in the center and south of the country (to 32 percent and 11 percent, respectively).
In 1990, 90 percent of the 218 urban water sources and 70 percent of the 1,191 rural water treatment plants produced potable water. Since that time, frequent power cuts and unauthorized connections have resulted in high levels of backflow, causing rapid pipe deterioration. Eighteen breakages of water supply pipes were reported during 1985-90; in the following six years 1,800 breakages were registered. These leaks caused an estimated loss of 55 percent of water supplies.
The population estimated to have access to clean water supplies declined from 92 percent in 1989 to 79 percent in 1995 and the volume of water pumped per capita declined from an average 330 to 218 liters per capita in Baghdad, 270 to 171 liters in other cities and 180 to 91 liters per capita in rural areas of the center and south from 1990-96. Continued power outages, decreased technical capacity among water technicians and continuing wear on the network of pipes slowed any improvement in water quality from the Oil-for-Food program. Nevertheless, water consumption per person doubled and the percentage of water samples that were safe to drink rose from 63 to 72 in the north and from 88 to 95 in the center and south in 1996-98.
Iraq was able to produce 9,295 megawatts (MW) of electricity per day in 1990. This exceeded demand by five to ten percent. Emergency repairs reestablished 2,300 MW production after the Gulf war in 1991 and 4,000 MW in 1996. Capacity rose to 4,400 MW in 1998 as new equipment replaced failing generators and switching equipment, but demand increased more rapidly. The excess in demand over production increased from 800 MW in 1996 to 1,500 MW in 1999, resulting in more frequent power cuts.
Oil-for-Food: Limited Impact
The value of nutrition and health commodities provided under the Oil-for-Food program — more than $14 billion from 1996-99 — far exceeds any previous humanitarian commodity supply effort in the world. It is also unique in that it is funded, under duress, by the government of the affected country.
One year after Oil-for-Food began, acute malnutrition declined in the north (1.7 percent) but remained high in the center and south (9.1 percent). In mid-1999, drought-related acute malnutrition rose in the north (3.4 percent), while improved rations resulted in a modest decline in malnutrition in the center and south (20.4 percent). 
Before the first Oil-for-Food medical supplies reached Iraq in May 1997, patient visits to health centers and hospitals, the number of X-rays, lab tests, surgical procedures and prescriptions provided by the public system of medical care had each fallen by about half. Only a third of women received prenatal care. In the first twelve months of the program, mainly as a result of improved access to medicine, the number of lab tests rose by 9 percent, the number of X-rays increased fourfold and the number of ambulatory visits to public hospitals increased by 46 percent.  The average number of days per month when essential medicines were unavailable at clinics in the center and south declined from 24 days per month in August 1998 to eight days per month that December. 
Improvements in access to medicine and food, however, appear to have had a limited impact on living conditions. Malnutrition has declined, but rates are still alarmingly high. This may be related to the medical system’s reliance on imported equipment and goods and its orientation toward sophisticated curative care. Many physicians were educated abroad in advanced clinical specialties but few public health or community health specialists were trained.
Few people now are skilled to reorganize services toward primary care or make difficult rationing decisions in the health system. Top officials have shown little interest in promoting a culture of adaptation, and the highly centralized political system is not oriented toward locally based, integrated problem solving.
Under the sanctions, Iraq is heavily isolated from potential international assistance in remodeling the health system. Major changes that were needed to encourage breast-feeding, promote measles immunization, introduce appropriate weaning foods, screen children and provide supplementary rations for those in need, boil water for drinking and provide early interventions for diarrhea and respiratory infections, were initiated only in 1995. The government has continued the high-tech, pro-curative bias under the Oil-for-Food program, devoting more funds to acquiring recent treatments and diagnostic equipment than to improving basic sanitation, which remains in crisis even within hospitals.
In Contrast: Cuba Under Sanctions
The Cuban economy declined by about a third from 1989-92 with the loss of trade and aid from the Soviet bloc. The US embargo, in effect since 1960, was tightened in 1992, worsening conditions. Cuba, like Iraq, has a centralized economy dependent mainly on international trade. Its large public sector had enjoyed sustained investments in health and education for several decades.
Despite these similarities, the differing responses of the two countries to sanctions are striking. As in Iraq, low-weight births in Cuba rose 19 percent in 1993, eliminating ten years of progress. The number of women with inadequate weight gains during pregnancy or with anemia also rose rapidly. The price of staple goods climbed, the purchasing power of salaries eroded and unemployment soared. The US embargo created an estimated virtual “tax” of 30 percent on all imports that had to be purchased from smaller and more distant markets. Total mortality per 1,000 inhabitants rose from 6.4 in 1989 to 7.2 in 1994, mainly due to a 15 percent rise in mortality among those 65 years of age and older, accounting for 7,500 “excess deaths.”
Cuba, like Iraq, depended heavily on imported food and also experienced declines in child nutrition. Cuba imported about half of all proteins and calories intended for human consumption during the 1980s. Imports of foodstuffs declined by about 50 percent from 1989 to 1993. Reduced imports and a shift toward lower-quality protein products were significant health threats. Milk production declined by 55 percent from 1989 to 1992 due to the loss of imported feed and fuel. A daily glass of milk previously provided to all children in schools and day care centers through age thirteen was restricted to children under age six. Per capita protein and calorie availability declined by 25 percent and 18 percent, respectively, from 1989 to 1992. 
Despite these threats to health, mortality among infants and children under five years in Cuba have continued to decline from already low levels since the US embargo was tightened in 1992. Cuba promoted breast-feeding, provided extra food to women and children in social centers and schools and stocked a small amount of emergency medicine to protect most women and children from the short-term threats posed by an embargo. Educational activities via mass media, teachers and doctors encouraged families to boil water, pay more attention to immunizing and feeding their children and breast-feed in response to the health threats from the embargoes.
The Cuban government was already skilled at rationing key goods and responding to embargo or crisis-induced shortages. The degree and extent of economic decline and the destruction of infrastructure in Iraq far exceeded that in Cuba. Nonetheless, the Cuban focus on mobilizing latent resources in education and health, mobilizing public participation to compensate for reduced access to capital goods, and the use of public systems to motivate behavioral change, with a focus on the needs of women and children, are important demonstrations of what can and should be implemented in Iraq.
This mobilization of basic resources to protect the micro-environment of the child has likely been responsible for decreased infant mortality in Cuba. Where mortality among children under five was already low in Cuba (13 per 1,000 in 1989), it declined further during the crisis caused by the intensified embargo (7.6 per 1000 in 1998). Despite a GNP per capita which was about one tenth of that in the US, and has since declined by close to a third. Cuba’s infant and child mortality rates are nearly as low as those of the US. This is a remarkable record of protecting health and wellbeing despite resource shortages and infrastructure deterioration.
Iraq’s embargo-induced lack of resources was exacerbated by other events. The war against Iran during the 1980s resulted in the destruction of health and social facilities in the heavily populated southern cities and towns prior to 1990. Large-scale air attacks during the six-week bombing campaign prior to the ground war in 1991 affected transportation, electric power and communications throughout the country.  In southern Iraq and in Kurdish territories in northern Iraq, post-war uprisings caused further destruction of basic infrastructure, affecting public health. After the Gulf war major facilities such as bridges and roads were rapidly repaired, but the country’s social infrastructure — health facilities, schools, electricity, water pumps and pipes — did not receive the same attention.
The deficit in these infrastructural assets greatly exacerbated the shortage in resourcesgenerated by the embargo. Even more difficult to quantify but crucially important in any such effort will be the extent to which resources — including popular initiative — are mobilized. Reconstruction of Iraq will proceed more rapidly and effectively if it includes stepped-up monitoring of social conditions, improved information systems to assure improved investments, expanded use of existing resources in education and health, education of the general population and a focus on key vulnerable population groups. The contrasting examples of Cuba and Iraq highlight the importance of strengthening health monitoring systems and refocusing health policy toward maximizing scarce resources and emphasizing preventative over curative medicine.
 Iraqi Economists Association, Human Development Report 1995 (Baghdad: United Nations Development Program, 1995).
 Richard Garfield, S. Zaidi and J. Lennock, “Medical Care in Iraq after Six Years of Sanctions,” British Medical Journal 315 (1997).
 UNICEF/Iraqi Ministry of Health, Child and Maternal Mortality Survey 1999, Preliminary Report (July 1999).
 UN Special Topics on Social Conditions in Iraq, 1999.
 Impact Assessment of SCR 986, Education Sector, MDOU, 1999.
 Food and Agricultural Organization, Evaluation of the Food and Nutrition Situation: Iraq (Rome, 1998). ES:TCP/IRQ/6713.
 Richard Garfield, “Studies on Young Child Malnutrition in Iraq, 1990-1999,” Nutrition Reviews, forthcoming.
 Report of the Secretary General Pursuant to Paragraphs 29 and 30 of Resolution 1284 (1999) and Paragraph5 of Resolution 1281 (1999), S/2000/208, United Nations, New York, March 10, 2000.
 UN Secretary General’s 180-Day Report, June 5, 1998, S/1998/477; and Report of the Secretary General Pursuant to Paragraph 6 of Security Council Resolution 1210 (1998). S/ 1999/197, United Nations, New York, 1999.
 Richard Garfield and S. Santana, “The Impact of the Economic Crisis and US Embargo on Health in Cuba,” American Journal of Public Health 87/1 (1997).
 A. Ascherio, R. Chase, T. Cote, et al., “Effect of the Gulf War on Infant and Child Mortality in Iraq,” New England Journal of Medicine 327/13 (1992).