Iraq teetered on the edge of the abyss even before the bombs began to drop. While watching war coverage on TV ,one is barraged by a numbing litany of appalling statistics showing the number of victims either because of the oppression of Saddam's regime (confirmed by the disclosure of the mass graves) and by the direct impact of the unprecedented strict sanctions imposed on the Iraqi people for more than 12 long years and most of the prey were children; along with corruption in the oil for food program which accompanied this blind punishment.. During the war the civilians again were the fuel of the collateral damages resulting from the military activities .The chaos of postwar Iraq crippled the rudimentary infrastructure and now after 4 years the crises is still unsolved.

Now the killing enemy is unidentified but the target is still the civilians and the situation is volatile and unpredictable. .How do we end the cycle? Where to begin is a hard question .The best efforts disappear into a gaping maw of endless need. If we take a triage approach then stability and rebuilding are intertwined goals .How can an economically war torn country like Iraq improve the health of their least advantaged citizens. It will be an uphill struggle. Which kind of miracle might we expect in order to regain peace and guarantee security in Iraq when policymakers neglect the poor people's interests in the formulation of their policies? Policymakers are frequently poorly informed about the lives of the poor miserable citizens on whose behalf they are designing their power. The sudden obligatory transferring from the state of decades of oppression and iron-fist tyrannical rule, towards democracy, is not the same as exporting jazz music, blue jeans and McDonald's swift meals, especially with the existence of the huge conflict of interests among neighbouring countries and the opprobrious behaviour of the occupational military officials which lead to further alienation between a population and its center of power. From our embryonic democratic process we learned that power and private interest remain far stronger governing forces in policy-making and that the poor citizens are often used to legitimize a political process to give it added credibility. Also lack of continuity of care and the politicization of the ministry further increase the problems. The ministry of health has had five ministers since the US invasion. Each has appointed people from his own religion or ethnicity and used personal discretion when allotting resources. It would be pointless to contribute additional funding to the country for health care until the ministry is depoliticised.

In the middle of the turbulent violence and chaos the big challenge is how to spend a limited national budget. Should a government invest more in health. The biggest problem in the health system lies with tertiary care. Hospitals are struggling to cope with shortages of qualified personnel. Shoddy and unsanitary buildings, and there is a lack of basic commodities ranging from linens to drugs.

In addition to dealing with constant shortages, health care providers, like many professionals in Iraq are the targets of violence and kidnapping. In a recent report the UN Assistance Mission for Iraq reports grim statistics on the fate of health providers. From April 2003, to May 2006, the ministry of health reported that 102 doctors were killed.164 nurses also died and 77 were wounded .In May 2006 alone, eight doctors and eight nurses were killed; the number of wounded were 42 and seven respectively. Some estimates indicate that as many as 250 Iraqi doctors have been kidnapped in the past two years. Health professionals are also victims of the increase in guns and violence, the UN reports. A group of physicians recently investigated the average number of bullets in the corpses of people killed in Iraq, finding the number between four to twelve bullets per person. Bullets cost between 10 cents and 40 cents each, so the cost of killing one doctor in Iraq can be as low as 40 cents.

The Special Inspector General for Iraq showed that only 32% of Iraqis have access to clean water and 19% to sewer services. Before the US invasion in 2003, 50% of Iraqis had access to clear water and 24% to sewer services). The health care community also seems to have lost sight of how fundamental clean water and sanitation are to health, preferring to get involved in more direct medical interventions such access to drugs and vaccination. It is dangerously short sighted to pour immense time and resources into vaccinating children only to have them die a few years later from diarrhoeal illnesses.

More than 34,000 civilians have reportedly died s and over what period of time? Should these questions be left to the elected politicians with the lack of trust between the different competing parties mixed in a national union government? To prevent a sectarian sedition, should they be left to technocrats or a sample of the public?

However other impediments remain; political instability, weak governance, and appalling corruption is hampering the solutions. In recent years newspaper business pages have been full of examples of corruption and criminal practices that lead to the enrichment of a few greedy individuals. Some, like the UN oil-for-food scheme, in which Kofi Anan's son Kojo was sadly implicated, had direct effect on people's well-being and livelihoods. The word 'corruption' -abuse of entrusted power for private gain, rarely enter health professional's vocabulary and is frequently softened to unethical, or unprofessional behavior and the politicians prefer to hide them behind the asphyxiating language of management. The corruption permeates the provision of health care at all levels because the health sector is particularly prone to corruption as it constitutes a maze of complex and opaque systems that provide a fertile ground for malfeasance. What is the scale of the problem? In terms of financial costs, it is impossible to state an exact figure, but the estimate goes into tens of billion of dollars per year. The spectrum of corruption ranges from physicians with conflicts of interests advocating a particular treatment for the wrong reason; from underpaid health worker accepting small bribes from patients; to the provision of ineffective counterfeit drugs; from large-scale embezzlement of public health funds; to massive distortions of health policy and funding by corrupt government officials.

While Iraq struggles to get a handle on violence and corruption, the state of its health-care infrastructure has been a hot topic in the USA. Recent government reports outline mismanagement of US reconstruction and delayed and shoddy work on both health care clinics and hospitals. Several democratic senators recently called for further investigation and possible sanctions for culpable contractors and US officials. As from June 28 2006, more than 88% of the US $ 750 million appropriated for health activities by the USA has been obligated and 65% has been spent according to the Special Inspector General for Iraq. I believe that the core of the problem is that the US officials had no experience in international health development in regard to the models they have driven, accompanied by Iraqis anxiety to restore their health system to pre-1991 levels when it was considered one of the best in the Middle East. The World Bank Senior public health specialist Jean-Jacques Frere says that overall the health sector received 4.8% of total US Iraq reconstruction funds. Of that 63% was allotted for construction while 34% was for equipment. Only 1% was oriented toward improving services for mothers and children and 2% for systems improvement and training.

Assessment of funding and program success in terms of health outcomes is patchy at best. This alarming picture is not exactly encouraging donors in an environment, which people call a mess, chaos, In this climate of violence there is nothing we can do. Policy makers in the developed countries should full understand that things never get better by being left alone, nor will ignoring the problems make them disappear .The daily street violence is limited to a few areas, so we can start in the relatively stable cities to jump on the fears from lack of security.

I think that the crises however is an opportunity for pioneers and far sighted people. .I 'd like to shed light on several subjects. Firstly it is the quality and the type of aid that matters just as much as quantity. Secondly we can start with relatively secured parts of the country, which is about fourteen governates from eighteen comprising Iraq. Finally any cure should start with maximum transparency. Donors and recipient governments need to grant easy access to information on health related projects, budgets and policies to allow independent audits. Any transgressions have to be rigorously prosecuted. By doing this not only enormous amounts of money but also many lives could be saved.

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Dr Safaa Bahjat, Kirkuk, Iraq
An exacerbation of poverty in Iraq - a personal perspective.
Poverty in the health system.