On August 2, 1990, the people of Iraq awakened to the disquieting news of their government’s sudden and brazen military occupation of neighboring Kuwait. Just four days later, amidst escalating international tensions, the UNSC passed Resolution 661, inaugurating a regime of near total economic sanctions on Iraq. This measure sought to coerce the Iraqi regime into retreating from Kuwait, paying reparations, and dismantling its arsenal of “weapons of mass destruction.”Footnote 1 The embargo severed Iraq from the global economy, stifling its vital oil exports and obstructing the flow of essential goods into the country.
Over the ensuing twelve years, these sanctions – referred to in Iraq as al-hisar (the siege) – unleashed a relentless unraveling of the nation’s social and economic fabric. Decades of progress in public health and education were rapidly reversed as the sanctions regime rendered Iraq isolated, impoverished, and rife with corruption. The widespread scourge of disease, environmental degradation, and pervasive suffering foretold the nation’s descent into a protracted humanitarian crisis. Among the most devastated casualties was Iraq’s once admired healthcare system, which crumbled under the dual pressure of infrastructural collapse and the mass exodus of its medical professionals.
This chapter examines the far-reaching and enduring legacies of the Gulf War and sanctions of the 1990s, with a particular focus on their catastrophic impact on Iraq’s healthcare system and medical practices. It contends that the twelve-year sanctions period constituted an “ecological event,” whose ripple effects disrupted the healthcare landscape long after the formal cessation of sanctions.
Bereft of vital supplies and faced with a surge in infections, Iraqi physicians were compelled to improvise, devising unorthodox methods in wound care and antibiotic use. While born out of necessity, these adaptations sowed the seeds of chronic and resistant infections, a crisis that continues to haunt Iraq’s beleaguered healthcare system. These medical challenges transcended Iraq’s borders, reshaping regional healthcare dynamics and aggravating a broader public health crisis.
Sanctions As Warfare
In recent decades, economic sanctions have often been portrayed as a gentler alternative to the overt violence of war, a diplomatic tool designed to exert pressure without resorting to military intervention. Framed within the paradigm of “global governance,” sanctions aim to enforce compliance from states, individuals, or entities by economically isolating them.Footnote 2 The underlying assumption is that such measures will compel political actors to align with international norms through the coercive power of economic deprivation.
Yet, a growing body of interdisciplinary scholarship has interrogated the paradoxes and profound consequences of sanctions, challenging the notion that they are a “humane” alternative to warfare.Footnote 3 While ostensibly directed at influencing state behavior on the international stage, sanctions frequently weaken a government’s capacity to shield its citizens from their fallout. The resulting economic and social upheaval disproportionately impacts the most vulnerable, disrupting livelihoods, undermining survival strategies, and corroding the social and political fabric of affected nations.Footnote 4
Sanctions, I argue, are not merely an alternative to war but a distinct form of warfare in their own right. Though devoid of direct military engagement, their effects can rival the destruction wrought by conventional armed conflict.Footnote 5 Comprehensive economic sanctions dismantle a nation’s socioeconomic infrastructure, precipitating humanitarian crises and inflicting enduring harm on civilian populations. These measures strike hardest at the margins, exacerbating scarcity, inflating process, and unraveling public health, education, and social services.Footnote 6
In this sense, sanctions constitute a “silent war,”Footnote 7 and their toll can be as widespread and destructive as traditional forms of violence. The long shadow they cast over nations extends far beyond their temporal application, leaving legacies of suffering and disarray that take decades to address. Recognizing sanctions as warfare is critical to evaluating their ethical and policy implications, as their true costs – often obscured in the immediacy of implementation – surface in the form of prolonged human misery.
The sanctions imposed on Iraq in 1990, combined with a devastating military campaign, represent a paradigmatic example of this silent warfare. These measures engendered an unparalleled humanitarian catastrophe, magnified by deliberate bureaucratic obstructions imposed by the US and Britain. These governments manipulated the delivery of humanitarian aid, employing tactics that ranged from outright denial to prolonged delays lasting months or even years to obtain approvals.Footnote 8
Joy Gordon’s meticulous research reveals the inner workings of this “invisible” machinery of war.Footnote 9 According to Gordon, the US was responsible for close to 90–95 percent of the holds placed on essential goods through “an opaque and arbitrary process in which billions of dollars of urgent goods related to food production, water treatment, road repair, electricity, transportation and telecommunications were prevented from arriving in Iraq for months or years.”Footnote 10 Billions of dollars’ worth of urgently needed items – ranging from food production inputs to water treatment systems and educational supplies – were withheld for prolonged periods, ostensibly due to concerns over their potential “dual use” for civilian and military purposes. Gordon explains:
Medicines were allowed in, but not the refrigerators or trucks needed for the cold chain, without which the medicines would be unusable. A water treatment plant was allowed – something of great urgency, given the epidemics of water-borne diseases such as cholera and typhoid – but not the generator needed to run the plant, with the rationale that it was dual use. Nearly all computer equipment was blocked on the same grounds, including computers needed for hospitals and schools. A wide range of educational goods were blocked, ranging from medical textbooks to equipment for teaching science at the secondary school and university level. Equipment for irrigation and desalinization was blocked or delayed for months or years, compromising Iraq’s agricultural production. Citing dual use concerns, fertilizer and pesticides were often blocked or delayed until the planting season was over, rendering them useless.Footnote 11
These capricious restrictions crippled Iraq’s essential services, creating cascading shortages that extended far beyond legitimate military concerns. Meanwhile, the Iraqi regime’s own actions – including obstructing inspections and exploiting the sanctions for political gain – further exacerbated the crisis. Amidst this maelstrom, the nation’s healthcare system bore the brunt of these compounded failures, standing as a stark emblem of the human cost of economic warfare.
In response to the economic devastation wrought by the sanctions, the Iraqi government implemented an array of measures to mitigate the breakdown of state infrastructure and social order. It prioritized increased agricultural production, established a nationwide food rationing system to stave off famine, and mobilized civilian and military resources for a national “Campaign for Rebuilding and Reconstruction,” which started after the ceasefire in 1991.
However, these efforts were accompanied by harsh, authoritarian policies that deepened the regime’s repression. Travel bans were imposed on government employees, punitive measures against petty crimes were intensified, and draconian punishments were meted out for activities perceived as undermining the national economy. Meanwhile, rampant inflation, the rapid devaluation of the currency, and chronic shortages of essential goods and medicines decimated the public sector, leaving ordinary Iraqis to bear the brunt of this economic siege. Nowhere were the impacts of these measures more acutely felt than in Iraq’s healthcare system.
Infrastructures, Undone
On January 17, 1991, a U.S.-led coalition of 31 nations launched “Operation Desert Storm,” a military campaign aimed at expelling Iraqi forces from Kuwait. Over the course of forty-three days, the coalition unleashed a relentless aerial bombardment and missile offensive on Iraq, targeting both military and civilian infrastructure. Deploying an unprecedented arsenal of advanced weaponry – including laser-guided missiles and depleted uranium artillery – this campaign overwhelmed the already demoralized Iraqi military, weakened from the grueling eight-year war with Iran. By the end of the campaign, Iraq’s military had been forced to withdraw from Kuwait, and a ceasefire agreement was declared on February 28, 1991.
The devastation wrought by Operation Desert Storm was staggering. The US and its allies dropped around 130,000 tons of ordinance – more than double what the Allies dropped over Berlin during World War II. Iraq’s vital infrastructure lay in ruins: Power plants and transmission lines were obliterated, roads and bridges were destroyed, telecommunications networks severed, and water purification and sewage treatment facilities rendered inoperable. A UN envoy described the aftermath as near-apocalyptic, likening the destruction to a regression to the pre-industrial age.Footnote 12 The cost of rebuilding this shattered infrastructure was estimated at $20 billion, a figure far beyond Iraq’s means in the stranglehold of sanctions.
Among the most critical losses was the decimation of Iraq’s electricity generation capacity. Prior to the war, the country produced approximately 9,000 kilowatts of electricity, sufficient to power its urban centers and industrial sectors.Footnote 13 The bombing campaign reduced this output to a mere 4 percent of its original capacity, leaving only two out of the nation’s twenty power plants operational.Footnote 14 This collapse of electrical infrastructure reverberated across all sectors, compounding the challenges faced by hospitals, water treatment facilities, and agricultural production.
Before the war, Iraq’s water supply infrastructure was a point of pride. The nation produced over 520 million cubic meters of treated water annually, with each Baghdad resident receiving an average of 450 liters per day. In other parts of the country, each person received over 200 liters per day, which were purified and delivered by numerous central water-treatment stations and over 1,000 smaller water projects.Footnote 15 The bombing campaign destroyed the country’s three primary chlorine production facilities and its sole aluminum-sulphate production site, crippling the ability to purify water. The output of treated water plummeted to 120 million cubic meters per year, while over 6,750 breaches in the water distribution network caused extensive leaks and shortages.Footnote 16 These disruptions led to an immediate surge in cholera, typhoid, and gastroenteritis.Footnote 17
Sewage treatment systems fared no better. The bombing disabled 216 sewage pumps, with another 262 rendered nonfunctional due to power shortage.Footnote 18 Raw sewage overflowed into urban neighborhoods, pooling in open areas and contaminating the Tigris River with an estimated 10 million cubic meters of untreated waste each month. Bacteriological analysis conducted in 1991 revealed that over half of the population tested in fifteen governates was exposed to fecal contamination in their drinking water. The poorest and most vulnerable communities bore the brunt of these public health crisis, which contributed to the alarming rise of infant and child mortality during the early years of the 1990s.Footnote 19
While considerable research has been devoted to the health effects experienced by US and UK military veterans of the Gulf War, the long-term health consequences for Iraq’s civilian population remain poorly documented.Footnote 20 Local studies, often constrained by limited resources and an exodus of scientific expertise, have struggled to provide a comprehensive picture.Footnote 21 However, the environmental and public health toll of the war was undeniable. Land and air pollution from burning oil fields, munitions contamination, and the destruction of chemical weapons facilities left enduring scars on Iraq’s ecosystem.
The bombing of Iraq’s Al-Muthanna State Establishment, once a hub for chemical weapons production, marked the largest ever airstrike on a nerve agent stockpile,Footnote 22 and has been implicated in exposing US troops to sarin gas, contributing to what has come to be known as Gulf War Syndrome.Footnote 23 This mysterious condition, characterized by a range of chronic health issues among Gulf War veterans, underscores the broader human and environmental toll of these chemical exposures. Within Iraq, toxic pollutants from bombed oil refineries and industrial sites further exacerbated public health challenges. The deliberate destruction of Iraq’s oil infrastructure, which led to the release of 3.5 million tons of crude oil into the environment and 800,000 tons into the Persian Gulf, compounded the environmental crisis.Footnote 24 Additionally, the widespread use of depleted uranium ammunition during the Gulf War and subsequent military campaigns has raised significant concerns about the long-term effects of chemical exposure, including spikes in cancers, birth defects, and other health issues among Iraqi children.Footnote 25 Together, these environmental assaults, amplified by a decade of crippling sanctions, entrenched a legacy of systemic decline in Iraq’s public health and institutional capacities.
Medicine in Crisis
Throughout its modern history, healthcare in Iraq has been instrumental in the consolidation of state authority and the continuity of statecraft.Footnote 26 The foundation of this relationship dates back to the British Mandate period (1920–1932), when medicine became a key vehicle for infrastructure expansion and a tool of socioeconomic development.Footnote 27 British and Iraqi physicians collaborated to establish a centralized public health system, culminating in the founding of Iraq’s first medical school in 1927. This milestone symbolized a commitment to developing a cadre of local doctors who would serve as both nation-builders and instruments of state outreach in urban and rural areas.
By the 1970s and 1980s, Iraq had emerged as a regional leader in healthcare.Footnote 28 The system, modeled on the UK’s National Health Service (NHS), provided free public-sector medical education and care. Medical students followed a rigorous six-year curriculum of studies based on UK standards, which were supplemented by residencies in public hospitals, mandatory rural service, and military postings as a form of reciprocity for state-funded education. This commitment extended to postgraduate training abroad, particularly in British and American institutions, ensuring that Iraqi doctors were equipped with the highest international standards of medical knowledge.
During this period, Iraq’s healthcare indicators showed remarkable progress. Under the Ba’athist rule, the expansion of socialist policies fostered significant improvements in maternal and infant mortality rates, access to healthcare, and nutrition standards.Footnote 29 The estimated per capita daily caloric availability rose from 1,958 in 1961 to 3,400 in the period from 1984 to 1990.Footnote 30 Even amid the grueling Iran–Iraq War (1980–1988), the healthcare system adapted and thrived, with investments in hospitals, medical schools, and primary healthcare.Footnote 31 Women’s organizations played an essential role in public health initiatives, driving vaccination campaigns, improving health literacy, and reducing mortality rates.Footnote 32
By the 1990s, Iraq’s healthcare system had grown into a comprehensive network of 131 hospitals and 851 health centers, serving nearly 90 percent of the population.Footnote 33 However, the Gulf War and subsequent sanctions shattered this system. Hospitals across Iraq, particularly in the south, were looted or destroyed during the Shi’a rebellion of 1991, while the sanctions inflicted further devastation on the daily operations of the medical sector. The lines between warfare and healthcare blurred, as sanctions exacerbated the collapse of infrastructure critical to public health.Footnote 34
The sanctions period devastated Iraq’s healthcare workforce. Beginning in the 1990s, Iraq experienced a persistent exodus of doctors and nurses, a trend that accelerated after the 2003 US invasion.Footnote 35 Medical professionals cited deteriorating training conditions, financial hardship, and the unsafe work environment as key factors driving their departure.Footnote 36 Compounding this brain drain, the intellectual embargo imposed by sanctions restricted access to updated medical literature, journals, and textbooks, leaving Iraq’s medical education system increasingly isolated from global advancements.Footnote 37
Nursing, a profession long underdeveloped in Iraq, faced a further breakdown under the sanctions.Footnote 38 The healthcare system, historically reliant on foreign nurses, was left with a diminished workforce as many expatriates returned home.Footnote 39 Local nurses, facing paltry wages and grim working conditions, abandoned their roles in favor of better-paying opportunities outside the healthcare sector. By the immediate aftermath of Operation Desert Storm, Iraq’s largest medical complex, Medical City, functioned with less than half of its nursing staff.
Healthcare workers bore the dual burden of enduring the economic collapse, while struggling to care for the vulnerable population under extreme resource constraints. Hyperinflation and the devaluation of the Iraqi dinar reduced healthcare workers’ monthly salaries to an equivalent of $3–$10. This forced many to seek second jobs, compromising their ability to serve the health system effectively.Footnote 40
By 2003, Iraq’s healthcare workforce had been decimated. The country had 53 physicians and 46 nurses per 100,000 people, figures that paled in comparison to neighboring countries.Footnote 41 For instance, Iran boasted 105 physicians and 246 nurses or nursing assistants per 100,000 people, while Jordan’s healthcare force was more than four times as robust. Particularly alarming was Iraq’s nurse-to-doctor ratio, which fell to less than 1 nurse per physician, far below the global standard of 3–6 nurses per doctor.Footnote 42
The Erosion of Care
For twelve years, Iraqi healthcare existed in a state of chronic collapse. The sanctions ushered in a breakdown of sanitation systems, a surge in infectious diseases, and pervasive environmental toxicity. These conditions not only strained the healthcare system but fundamentally altered how Iraqi doctors approached care in their daily practice.
In the immediate aftermath of the Gulf War, hospitals across Iraq operated at a fraction of their previous capacity. Occupancy rates plummeted by 30–50 percent, with some facilities experiencing reductions in laboratory and radiology services exceeding 80 percent.Footnote 43 At Baghdad’s primary teaching hospital, only two-thirds of the medical wards and half of the surgical wards remained functional.Footnote 44 Outpatient clinics, meanwhile, faced crippling disruptions. Between 1989 and 1992, the number of major surgeries performed monthly fell from 15,125 to 5,477 – a figure that remained stagnant for the rest of the decade.Footnote 45
As the sanctions deepened, conditions in Iraqi hospitals rapidly deteriorated. The economic stranglehold system imposed by the UNSC disrupted the importation of critical medical supplies, undermined preventive and curative services, decimated the infrastructure for controlling infectious diseases, and hampered local drug production. Chronic shortages of medication left patients with long-term illnesses in constant distress, while surgical procedures became increasingly hazardous due to the lack of essential equipment and sterile environments.Footnote 46
Despite the escalating need for medical supplies, the Iraq Sanctions Committee systematically put “holds” on medical goods purchased through the OFFP, delaying the import of these goods. The holds on critical goods, particularly those related to the infrastructure, increased throughout the decade. By the early 2000s, the volume of medical items placed on hold had tripled, from $150 million in 2000 to $450 million in 2002.Footnote 47 These included air compressors, insecticides, spare medical parts for sterilizers and autoclaves, oxygen concentrators, electrical generators and cables, sprayers, freezers, and accessories for oxygen production plants. Even laboratory materials, medicines, and dental laboratory equipment were not spared, exacerbating an already critical situation in Iraq’s healthcare system.Footnote 48 The inability to procure such items left hospitals ill-equipped to provide even rudimentary care.
In 1996, a comprehensive survey of Iraqi hospitals and healthcare centers – covering nearly 20 percent of Iraq’s civilian institutional beds – painted a grim picture.Footnote 49 The report revealed that one-third of hospital beds were closed, and the average length of stay was less than half of the pre-Gulf War period. Nearly half of the surveyed hospitals reported that diagnostic and therapeutic equipment was nonfunctional due to a lack of spare parts or maintenance.Footnote 50 Basic utilities, such as lighting, clean water, and sewage treatment, were universally compromised, with years of neglect rendering plumbing systems irreparable. The report grimly noted that “every hospital we visited had leaking sewage pipes.”Footnote 51 Many toilets were broken; those that remained operational were overcrowded, unsanitary, and plagued by infestations of flies, vermin, and insects.
The dire situation extended to hospitals maintenance budget, which had been slashed to unsustainable levels. At one 200-bed hospital, the monthly cleaning budget was reduced to a mere IQD1,500 (approximately $2), sufficient only to purchase hand soap for operating theatres. Without access to disinfectants or antiseptics, cleaning staff were limited to using just water for sanitation. Compounding the issue, staffing levels plummeted; for instance, the number of cleaning staff at this hospital fell from twenty to just two.Footnote 52
Essential medical supplies were similarly scarce. Hospitals reported frequent shortages of intravenous fluids, cannula tubes, urine catheters, sterile gloves, and surgical stitches – items fundamental to routine medical and surgical procedures. The unavailability of anesthetics and surgical material forced hospitals to cut daily elective surgeries drastically. In Mosul, for example, the number of such procedures fell from fifteen to two.Footnote 53 Surgeons were compelled to economize, reusing sutures and rationing painkillers like pethidine, an opioid, which became so scarce that ampules had to be distributed among patients.Footnote 54 The breakdown of sterilizers and autoclaves, coupled with delays in obtaining replacement parts due to sanctions, further jeopardized patient safety and postoperative outcomes.Footnote 55
Patients bore the brunt of these deficiencies. Many were required to bring their own blankets and heating units during the frigid winter months and to endure sweltering conditions in summer due to nonfunctioning cooling system.Footnote 56 Laboratory services also suffered a significant decline, with investigations dropping by 54 percent, during the first four years of the sanctions,Footnote 57 and a further 14 percent by 1997.Footnote 58 A WHO estimated that by the same year, only 25 percent of the medical equipment in Iraq’s healthcare facilities remained operational, crippled by restrictions on imports and lack of financial resources.Footnote 59 Broken refrigeration systems in vaccination centers hindered the preservation of vaccines, undermining immunization programs and leaving vulnerable populations exposed to preventable diseases.Footnote 60
The pharmaceutical sector, once a cornerstone of Iraq’s healthcare infrastructure, also collapsed under the combined pressures of war and sanctions. Before the 1991 war, the State Company for Drug Industry and Medical Appliances (SDI), established in 1965, supplied 60 percent of Iraq’s primary care needs, particularly antibiotics, analgesics, antiparasitic agents, local anesthetics, intravenous fluids, insulin, and digoxin.Footnote 61 However, the sanctions imposed severe limitations on the importation of raw materials and spare parts, crippling production.Footnote 62 International monitors repeatedly blocked shipments of essential supplies, citing concerns over potential dual-use applications.Footnote 63 By 2001, SDI’s production capacity had dwindled to a fraction of its former output, leaving hospitals reliant on irregular and inadequate external supplies. A WHO report noted that “holds on chemical and equipment imports are preventing SDI from restarting all its activities, and initial orders for externally manufactured drugs have not sometimes anticipated the resulting gap in supplies.”Footnote 64
In 2002, a joint UN team revisiting the SDI facilities highlighted the persistent challenges of unfulfilled contracts. While packaging materials had been approved and delivered, the critical machinery and raw materials necessary for production remained on hold, perpetuating the pharmaceutical shortages.Footnote 65 These systematic barriers rendered Iraq dependent on unreliable external supplies and an emerging black market of counterfeit and expired medications, further compounding the nation’s healthcare fallout.
While much of the writing about Iraq’s healthcare under sanctions has focused on external observations, the voices of Iraqi doctors themselves remain scarce in this body of work. One notable exception is Hazim Barnouti, a leading general surgeon and medical educator, who penned a stark appeal to the international medical community in the British Medical Journal in 1996. Reflecting on the grim realities of surgical practice under sanctions, Barnouti wrote, “The six-year blockade of Iraq has left surgery in a state that falls below minimally acceptable standards of safety and efficacy.”Footnote 66
In his commentary, Barnouti detailed the cascading consequences of supply shortages: a lack of antibiotics, the unavailability of sutures, the reuse of surgical gloves, and the breakdown of critical equipment. The persistent scarcity of anesthesia and antiseptic solutions severely undermined infection control, leading to a surge in postoperative complications. Without access to proper antibiotics, patients were at greater risk of fatal infections, while shortages of surgical supplies rendered even routine procedures fraught with danger. Barnouti painted a grim picture of the operating theatre, explaining, “Repeatedly reusing sterilized surgical gloves means they have large numbers of holes. Without money to replace them, badly torn surgical gowns and towels compromise aseptic technique and increase rates of wound infection. These have also increased because of shortages of antiseptic solutions for skin preparation.”Footnote 67
Operating under these suboptimal conditions, doctors were forced to improvise and economize, often at the expense of patient safety.Footnote 68 At a Baghdad teaching hospital, the theatre manager was permitted to issue only three pairs of surgical gloves per operation. In some cases, the same suction tube was used for multiple patients. Orthopedic surgeons were compelled to delay procedures, with one case requiring a patient to wait until a plate and screws could be removed from another patient during surgery.Footnote 69 As I have recounted elsewhere, “Doctors reused cannulas to economize, replaced Foley catheters with nasogastric tubes to empty bladders, and sterilized disposable gloves and remains of surgical sutures to be used on the next patient.”Footnote 70
The sanctions not only decimated Iraq’s healthcare infrastructure but also reshaped the very ecology of medical practice. Forced to adapt to chronic shortages, Iraqi doctors developed strategies of improvisation and resourcefulness, which, while lifesaving in the short term, entrenched systemic vulnerabilities. These changes – born of necessity – would leave a lasting imprint on Iraq’s healthcare system, sowing the seeds for future problems, including the rise of antimicrobial resistance (AMR) and the collapse of institutional care norms.
Resistance Rising
The sanctions era drastically altered how Iraqi physicians approached wound care and the use of antibiotics. With healthcare systems pushed to the brink, postoperative infection rates soared. By 1997, hospitals reported infection rates for clean wounds rising from 5 percent to an alarming 25–30 percent.Footnote 71 These heightened risks forced doctors to adopt preventative measures, often involving the indiscriminate use of broad-spectrum antibiotics. Regardless of the procedure, patients were prescribed multiple antibiotics to combat potential bacterial and fungal infections. Yet the unpredictable supply of antibiotics frequently interrupted treatments, leading to suboptimal dosing, reliance on expired drugs, or abrupt changes in medication based on what was available.Footnote 72 As hospitals struggled to secure consistent supplies, many patients and their families turned to the black market, which became flooded with counterfeit and expired drugs. Others relied on relatives abroad to send life-saving medications, highlighting the fractured state of Iraq’s pharmaceutical system. Even within hospitals, doctors had to contend with limited resources. Instead of basing prescriptions on laboratory-confirmed diagnoses, they relied on clinical judgment, as laboratories lacked the reagents and equipment needed to conduct sensitivity testing. These conditions created a breeding ground for antibiotic resistance, where partial courses of treatment or ineffective drugs allowed infections to persist and evolve.Footnote 73
The consequences of these practices were devastating. Patients who survived surgery often succumbed to chronic, resistant infections, with septicemia becoming an increasingly common cause of death. Doctors faced heartbreaking decisions as they battled infections with inadequate tools, knowing that even their best efforts might not suffice. Writing about their experience this period, Muhammed Akunjee and Asif Ali explain described the fatal impact of limited medical options:
Common bacterial and fungal infections, usually easily controllable with appropriate antibiotic and antifungal agents, have become fatal conditions. Patients presenting with infection are empirically treated with gentamicin and ampicillin at the onset of symptoms, since no alternative antibiotics are available. If there is no response, the infection spreads and the patient more often than not dies. The only antifungal available is ketoconazole, but this is rarely used due to problems of hepatic toxicity. More efficacious medication such as amphotericin B and fluconazole are simply unavailable. It is feared that the overuse of certain medications will lead to antibiotic resistance in the long-term. It seems only a matter of time before infectious epidemics become widespread in Iraq with the lack of appropriate treatment available.Footnote 74
Writings about the Iraqi healthcare system under the sanctions have captured a grim reality of the collapse of a once functioning system as its material and human infrastructures were undermined. A substantial portion of these portrayals, however, are episodic recollections of that period. Regrettably, comprehensive long-term studies that could have chronicled the progression of these repercussions over time are lacking. Furthermore, the Iraqi government’s assertions about the sanctions’ impact were often disregarded as state-spun propaganda, with allegations that the impact of sanctions was being manipulated by the regime. It is important to note, however, that the realities and the ongoing impacts of the sanctions era did not cease with the lifting of the sanctions. In fact, the biosocial consequences of the health system’s downfall in Iraq have characterized the post-sanctions period, significantly influencing the degradation of the nation’s healthcare for many subsequent years.Footnote 75
The overreliance on antibiotics during the sanctions period reflected not just a desperate attempt to save lives but a systemic collapse of infection control and surveillance. These improvised medical practices, while unavoidable at the time, laid the foundation for Iraq’s ongoing crisis of AMR. The ramifications of this silent epidemic would extend well beyond Iraq’s borders, underscoring the far-reaching consequences of a healthcare system under siege.
Afterlife of Sanctions
A month into the 2003 US-led invasion of Iraq, military doctors began reporting a stubborn and alarming infection among wounded soldiers. The cause was the multidrug-resistant Acinetobacter baumannii, a bacterium later nicknamed “Iraqibacter.”Footnote 76 This pathogen, resistant to most antibiotics, traveled with returning soldiers to US hospitals, where it infected individuals who had never set foot on a battlefield.Footnote 77 Over the next decade, military reports documented the growing resistance of this and other infections during deployment in Iraq. These reports often attributed this crisis to Iraq’s healthcare system, which had been decimated by sanctions, war, and neglect.Footnote 78 Neighboring countries’ hospitals, inundated with displaced Iraqi patients, similarly reported heightened rates of AMR,Footnote 79 underscoring the regional ripple effects of Iraq’s healthcare collapse.Footnote 80
Recent reports from antibiotic stewardship programs in Iraq reveal that AMR has become an endemic problem in the country’s hospitals. Rates of resistance to common antibiotics are alarmingly high, with many healthcare facilities struggling to combat infections that no longer respond to available treatments. A stark example of this problem is seen in the city of Mosul, where a recent Doctors Without Borders report revealed that nearly 86 percent of infections at its trauma hospital were resistant to most antibiotics available on the market.Footnote 81 Local doctors attribute this alarming figure to practices entrenched during the sanctions era: the overuse of broad-spectrum antibiotics, inadequate sanitation, and a lack of antibiotic stewardship protocols in both public and private hospitals.Footnote 82 Compounding this issue, the lifting of the sanctions in 2003 led to the emergence of unregulated drug markets, further undermining efforts to establish effective infection control and antibiotic management. This underscores the long-term effects of the sanctions era, which disrupted infection control protocols and encouraged the overuse of antibiotics as a reactive measure. Yet, within Iraq itself, there has been little systematic study to fully capture the scope and scale of AMR. The absence of comprehensive data leaves critical gaps in understanding how resistant pathogens have proliferated and what measures are most effective in curbing their spread.
As the global community confronts the escalating threat of AMR, Iraq highlights how war and sanctions serve as potent drivers of this global health crisis. The misuse of antibiotics during the sanctions era, compounded by the collapse of healthcare infrastructure and the chaos of war, created an ecosystem where resistant infections could proliferate unchecked. This crisis is not merely a localized issue but a reflection of how conflict and economic warfare disrupt health systems, amplify vulnerabilities, and allow AMR to transcend borders. Addressing this challenge requires not only medical interventions but also a reckoning with the broader historical, social, and political forces that have turned Iraq into a focal point for the global AMR epidemic.
The enduring impact of sanctions on Iraq’s healthcare system cannot be understood in isolation; it is deeply embedded in the broader histories of war, economic blockade, and systemic neglect. These forces not only dismantled healthcare infrastructure but also left behind a fragmented narrative. To fully grasp the afterlife of sanctions, it is necessary to go beyond surface-level accounts and examine how these intersecting pressures reconfigured Iraq’s medical landscape, creating conditions that persist today. This calls for a more rigorous engagement with the ways in which sanctions reshaped not only the material conditions of healthcare but also the social and institutional frameworks that underpin it.
Writings about the Iraqi healthcare system under sanctions have vividly captured the grim reality of a once functional system brought to its knees, as its material and human infrastructures were systematically eroded. However, much of this body of work consists of episodic recollections, offering fragmented snapshots of the crisis rather than comprehensive, long-term analyses of its progression. The absence of sustained studies has left critical gaps in understanding the complex and layered nature of this collapse, obscuring the intricate ways in which sanctions transformed healthcare into a site of systemic failure. The healthcare crisis under sanctions is not merely a story of material deprivation but a profound reconfiguration of Iraq’s medical ecology. It encompasses the disintegration of infection control protocols, the unchecked rise of AMR, and the permanent loss of professional expertise as doctors and nurses fled in waves. These are not just isolated events but are also interlinked processes that have redefined Iraq’s capacity to care for its people. The need to document and study this history more systematically is urgent – not only to capture the full scale of the collapse but also to understand how sanctions reshaped the foundational principles of healthcare delivery and its aftermath.
Studying this history requires moving beyond the immediate context of the sanctions to interrogate their long-term impact on Iraq’s medical and public health institutions. How did sanctions entrench systemic weaknesses? What lessons can be drawn from this protracted medical collapse? Addressing these questions is crucial not only for Iraq but also for global health, as the aftermath of such interventions continues to ripple across borders in the form of antibiotic resistance and fractured regional healthcare systems. By documenting this history, we can begin to understand how the interplay of war, sanctions, and state collapse rewrites the possibilities of care – leaving nations to grapple with the enduring scars of economic warfare.
In conclusion, the repercussions of the sanctions imposed on Iraq extend far beyond the immediate dismantling of its healthcare system. They have created a lasting legacy of biosocial vulnerability, embedding structural weaknesses that continue to destabilize public health in Iraq and the region. The rise of AMR in Iraq is emblematic of these enduring impacts, highlighting the need for a multidisciplinary approach to understanding and addressing the aftereffects of sanctions and war. The long shadow of sanctions underscores a fundamental truth: Even when framed as nonviolent tools of diplomacy, their effects can rival the devastation of war, leaving wounds that endure for generations.
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