The health and nutrition situation in the north

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 avail able 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 1,214 to a maximum of 1,765. 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 population. 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.

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