Background to Iraqi Health Care System

Since the 2003 invasion of Iraq and the subsequent fall of the Saddam Hussein regime, the Iraqi health care system has been in great need of reconstruction. The conflict almost destroyed Iraq’s primary health care delivery, disease control and prevention services as well as health research infrastructure. Much of the damage inflicted in these years still has an impact today. 96.4% of the Iraqi population do not have health insurance. As such, they are dependent upon the Iraqi central government-run public health care system. Decades of war and economic sanctions have caused serious damage to the health status of Iraq’s population. Whilst health care facilities have been rebuilt in many urban centers, facilities in rural and remote areas are still in poor condition. Further, poor levels of hygiene in many health facilities continue to have a severe impact upon the care delivered to patients. Health services have deteriorated as the sector has continuously faced shortages in medicine and other supplies. In addition, the current ongoing conflict has caused further damage to the country’s health infrastructure. A large number of health workers have fled the country, thereby further compounding the population’s inability to access health care.

Fallujah

Fallujah is a city in the Iraqi province of Al Anbar, located around 69 kilometers to the west of Baghdad and situated on the Euphrates. Fallujah once had a population of 350,000, although this has significantly decreased in recent years. In January 2014, the Islamic State (ISIS) tightened their grip on the city, importing large numbers of fighters and weapons. In the first days of 2014, an ISIS fighter addressed crowds in the city at Friday prayers and declared the establishment of an “Islamic Emirate” in Fallujah. Over the following two and a half years, ISIS grew stronger within the city, preventing families from leaving and enforcing its own laws. This included the imprisonment and torture of civilians. In June 2016, Iraqi government forces launched an offensive and regained control of the city. On 17 June 2016, Iraqi special forces declared that they had fully regained control of the city as they surged into the city center and raised the national flag above a government compound. The fierce fighting led to 85,000 people fleeing the city. The internally displaced persons (IDPs) now find themselves in makeshift camps around the area.

Health Care under ISIS

ISIS militants frequently punished those found to criticize their rule. This, coupled with the frequent electricity cuts in Fallujah which limited internet access, resulted in little accurate information leaving the city describing the state of healthcare during ISIS’ rule. When Iraqi special forces regained control of the city, they did find functioning medical clinics. Nevertheless, it does not seem that these medical clinics were used to properly serve the needs of the civilian population.

On 5 June 2014, aid workers from the International Committee of the Red Cross (ICRC) reported that they had successfully delivered medical supplies to Fallujah General Hospital. It was the first time ICRC staff had been able to enter the city since January 2014. The organization reported that the people of Fallujah were enduring a severe shortage of food, water and health care. In addition, the hospital, which was the only facility still able to provide treatment, had been seriously affected by the fighting. The medical supplies delivered were immediately used to treat casualties.

Rabiah Hassan, a woman who fled Fallujah when the city was retaken by Iraqi forces, recounted the mistreatment she encountered when she took her daughter to hospital. The Islamic State doctor, who had been brought from Mosul, said he would only operate if she gave him her daughter to marry. Instead of accepting the offer, Hassan left the hospital without her daughter receiving medical care.

Fallujah’s General Hospital, the main hospital in the city, was reportedly a centerpiece for ISIS. Following the ISIS takeover of Fallujah, the Iraqi health ministry withdrew its own doctors and nurses. ISIS medical staff from Palestine, Egypt, Syria and Chechnya, alongside Iraqis, were put in their place. The hospital is believed to have been used in a video made by the group to recruit international medical staff.

Civilians suffered not only as a result of the violations committed by ISIS forces, but also due to actions of the Iraqi government. Between February and December 2015, indiscriminate air and artillery shelling carried out by government forces killed many civilians. Government forces repeatedly struck Fallujah General Hospital with mortar and artillery shells.

In March 2016, Al Jazeera reported that thousands of civilians in the city were “dying of hunger.” Residents and local officials reported that the city was suffering from shortages of food, fuel and medicine. Hospitals in the city were operating with minimum capacities as a result of the shortage of medical supplies. Further, there had been an increase in the number of casualties because of frequent bombing by government forces. Medical sources from Fallujah’s general hospital said a woman had been killed whilst seven others were injured after Iraqi forces shelled several neighborhoods in central Fallujah.

In May 2016, as Iraqi security forces began a heavy bombardment of Fallujah, the Iraq country director for the Norwegian Refugee Council (NRC) stated that citizens had been suffering from food and medical shortages over the preceding months. In June 2016, Karim al-Nuri, a military spokesman of the People’s Militia stated, “Civilians are forced to donate blood to wounded extremists, often in unrestrained quantities, which leads to the donor dying due to excessive blood loss.” In June 2016, a joint press statement from the UN and its partners reported that residents had been living with acute shortages of food, medicine and other basic services such as water supplies. Humanitarian actors had been unable to reach anyone in the city for almost a year.

Barred from Baghdad

When the Iraqi army began the offensive to regain control over Fallujah, it triggered an exodus of civilians who had been trapped inside the city. On 20 June 2016, it was reported that over 82,000 civilians had evacuated Fallujah, with a further 25,000 en route. Iraqis fleeing battles in other cities had found refuge in other cities such as Baghdad, and had been able to access some level of support from other civilians, particularly family and friends. However, thousands fleeing Fallujah were barred from entering Baghdad. Near a camp in the town of Beziebez, thousands hoping to cross a bridge over the Euphrates River to stay with relatives in the capital camped out whilst waiting for permission to cross. Because Iraqi forces suspected that ISIS supporters could be hidden amongst the refugees, families were not allowed into the capital. On 25 June 2016, it was reported that some 20,000 teenage boys and men leaving Fallujah were being screened by Iraqi security forces. One detainee who was detained for four days by the Popular Mobilization forces reported that he had not been given anything to eat or drink during the time he was held. Other detainees reported being beaten and tortured by security forces. The mass interrogation of men leaving Fallujah has left many women and children without the males in their family as they flee to nearby refugee camps. A spokesman for Iraq’s Migration and Displacement Ministry, Sattar Nawrouz, said concern that militants would pose as displaced people had complicated the relief effort, but insisted that it was unavoidable given the recent history of Fallujah. Many civilians leaving the city complained of not being permitted to leave Anbar province, even for medical treatment. These people had no other option than to go to already vastly overcrowded camps for the displaced.

Ill-equipped Camps

The vast influx of civilians fleeing Fallujah to camps in the surrounding area has overwhelmed aid agencies who were unprepared for the number of people. On 6 June 2016, the UN and its partners released a statement stating that the camps established by the Government of Iraq for 60,000 people displaced in Anbar province were already overstretched, and would struggle to take in any more people. In the preceding ten days, 10,000 people had arrived in these under-resourced camps having fled from Fallujah.

By 20 June 2016, over 80,000 people had fled the city. Many of those found themselves without shelter and enough water in sandstorms and temperatures of 115 degrees. Aid agencies reported that in four makeshift tent cities there was only irregular electricity and a lack of latrines. According to the NRC, one site which was providing for around 1,800 people had just one latrine. Families fleeing from Fallujah had been forced to sleep in the open desert for almost a week, raising concerns of casualties supplies of tents and water were not increased.

Health care workers at the Habaniya camp, situated to the west of Fallujah, reported treating around 1,200 people per day who were suffering from malnutrition and other illnesses. Relief workers in other camps reported that pregnant women, children, the elderly and those with disabilities were particularly vulnerable, with some of them collapsing from exhaustion. Aid workers with the NRC reported that conditions within the camps were deteriorating. An emergency coordinator for Doctors Without Borders (MSF), Ghassan Abou Chaar, said that the toll in the camps was mental as well as physical. He reported that those who had fled Fallujah were at a breaking point. NRC Iraq Country Director Nasr Muflahi said, “Safe drinking water, latrines and medical care remain an immediate priority and extremely urgent.” Humanitarian agencies were concerned that the poor sanitation could spread infectious diseases like cholera and skin diseases as well as exacerbating chronic illnesses.

On 23 June 2016, Karl Schembri of NRC said, “We’re just struggling to deal with the basic necessities – water, food, medicines, tents, mattresses.” He said that, whilst aid agencies struggled to provide these basic items, dealing with the high levels of trauma of the displaced people was not a consideration. In an earlier interview on 18 June 2016, Schembri said that those arriving at camps were weak, malnourished and traumatized. Aid workers at the camp were having to slowly reintroduce food to people arriving at the camp, because they had spent months eating nothing but dates, animal feed and drinking river water contaminated by dead bodies. He added that the situation was so serious that they had to instruct people to break their Ramadan fast in order to receive vital nourishment.

Ralf al-Haj, the Red Cross spokesman in Baghdad said, “Most of the families in the camps haven’t had proper medical care for almost two years, and that puts in danger all those who have chronic diseases, while the health of the children is being compromised.”

Health Care Violations

The Iraqi conflict is classified as a non-international armed conflict (NIAC); certain international humanitarian law (IHL) is applicable. Parties to the conflict have obligations which arise by operation of Article 3 common to all four Geneva Conventions, which sets forth minimum standards for the proper treatment of people within a warring party’s control. Further, Additional Protocol II to the 1949 Geneva Conventions is applicable. Whilst Iraq did not ratify Additional Protocol II, it is widely recognized to be customary IHL. As such, non-State and State actors are bound to uphold the standards it sets out. While groups such as ISIS do not recognize IHL, members may still be held accountable before the International Criminal Court (ICC) for serious violations of international humanitarian law that are committed with criminal intent, which thus constitute war crimes.

  1. Common Article 3 Violations

Article 3(1) mandates that all persons taking no active part in the hostilities shall in all circumstances be treated humanely. ISIS violated this regulation by not permitting the entry of crucial food and medical supplies into Fallujah. The resulting starvation of many residents, as well as the obstruction of access to adequate health care caused by limited medical supplies, violate the obligation to treat civilians humanely. Further, forcing civilians to donate blood breaches Article 3(1)(a) which prohibits cruel treatment and Article 3(1)(c) which prohibits outrages upon personal dignity. The denial of access for humanitarian organizations also violates the prohibitions set forth by Common Article 3. The torture of men and teenage boys who were detained for screening as they fled Fallujah violates Article 3(1)(a) which prohibits torture.

  1. Additional Protocol II Violations

Additional Protocol II Article 18(2) mandates that relief actions be organized for the civilian population in need, but does not contain a specific provision on access to humanitarian relief. Nevertheless, such access is vital for relief efforts. Therefore, the denial of access of humanitarian organizations which took place during the period ISIS was in control of Fallujah violates this article. The prohibition of access to Fallujah, and the resulting effect on food and healthcare within the city, breaches Article 4 (b), which prohibits collective punishment.

The shelling of Fallujah General Hospital by Iraqi government forces breached Article 11, which specifies that medical units and transports shall be respected and protected at all times and shall not be the object of attack.

Medical Impartiality

The principle of medical impartiality states that no person or group shall interfere with the access to or delivery of medical services in times of conflict and civil unrest, and medical personnel shall not discriminate or refuse care to anyone injured or sick during times of conflict and civil unrest.

The element of non-interference in medical impartiality prohibits attacks on medical services, obstruction of a patient’s access to medical services, and the obstruction of medical personnel’s access to patients. The Iraqi government is in violation of this principle, as it has obstructed civilians fleeing Fallujah from accessing health care in Baghdad. Civilians have been forced to return to massively overcrowded camps for IDPs; this constitutes a clear breach of their right to the highest attainable standard of health care adequate for their health and well-being. The attack on Fallujah General Hospital also breached this principle, which prohibits attacks on medical infrastructure.

The element of non-discrimination in medical impartiality states that medical professionals may not refuse care to any person or people, ensures the humane treatment of all civilians in need of medical care, and the nondiscriminatory treatment of those injured and sick. The instance of an ISIS doctor refusing to treat a woman unless she was given to him to marry, and any instances similar in nature, clearly violates this principle. Doctors have a duty to indiscriminately treat all those in need of medical care.

Conclusion

ISIS has continued to commit atrocities in Fallujah, which could amount to war crimes or crimes against humanity. In dealing with an organization such as ISIS, there is little possibility of carrying out procedures to encourage the group to comply with IHL. International organizations such as the UN Human Rights Council and Western-government supported teams must continue to conduct investigations which could provide the material needed to establish atrocities in court, and thus bring offenders to justice.

The Iraqi government has an obligation to respect IHL. ICRC training must take place so that all warring factions understand the laws of war and are thus better equipped to uphold its obligations. In particular, the militias charged with screening men leaving Fallujah must be educated in order to avoid abuses taking place during this process. Further, the Iraqi government must cease attacks on medical facilities and allow civilians to access healthcare in other provinces and cities.

Finally, one of the greatest obstacles for civilians in reaching health care has been the lack of facilities available in displacement camps. Aid agencies have cited underfunding as a severe impediment to their ability to provide adequate health care to the large number of civilians who fled Fallujah in a relatively small period of time. Iraq’s UN-led humanitarian appeal has received just 36 percent of the $861 million it needs for 2016, although $36 million has been newly pledged. Nasr Muflahi stated, “What we’re seeing is the consequence of a delayed and heavily underfunded response with an extreme toll on the civilians fleeing from one nightmare and living through another one.” The international community has a responsibility to ensure that the necessary funding is supplied in order to avoid a humanitarian disaster. This is all the more important given the probability of a greater number of people fleeing from Mosul in similar conditions in the future.