The Endangered Asian Century
America, China, and the Perils of Confrontation
In early April, a video of an elderly woman in what looks to be a makeshift isolation ward in Iraq circulated widely on WhatsApp, shared by Iraqi doctors and journalists alarmed by their country’s apparent inability to contain the novel coronavirus outbreak. The woman, who is dressed in a blue hospital gown, struggles to breathe, but there is no oxygen mask over her face and no doctor nearby. Instead, another woman prays over her while a third bangs at the door, desperate for help that doesn’t appear to arrive.
Other reports coming out of Iraq paint a picture of an overwhelmed health-care system. Worried about impending shortages of personal protective equipment, doctors are reusing N95 masks. The country has just 1.4 hospital beds and 0.8 physicians per 1,000 people—less than half the levels in some nearby countries. The Iraqi government claims there are only about 1,500 COVID-19 cases countrywide, but the actual number may be far higher—Iraq hasn’t tested at large scale. Nor does it have the surveillance capacity for rigorous contact tracing and monitoring. One physician at a Baghdad hospital told me that he and his colleagues are seeing 50 new COVID-19 cases a day—and it is getting worse. “We are not prepared,” he said.
Decades of war have wrecked the country’s health infrastructure and made it particularly vulnerable to the disease. Two years after the defeat of the Islamic State (or ISIS), 1.5 million people are still internally displaced, without regular access to basic sanitation let alone health care. Most workers make a living in the informal sector, meaning that they now face a stark choice: continue working and risk infection or stop and risk starvation.
The government is in a poor position to help. Nationwide protests forced the prime minister to resign last fall, and now there is no confirmed cabinet. Making matters worse, the price of oil, which accounts for 90 percent of the government’s revenue, has plunged since March. Even in normal times, the government’s priorities skew toward security over services such as health care: in 2019, after the fight against ISIS had ended, the Iraqi government allotted 18 percent of its budget to its security forces and less than three percent to the Ministry of Health.
But it is not just the Iraqi government that bears responsibility for the country’s vulnerability to the pandemic; the United States is also responsible. The U.S. and UN sanctions regime of the 1990s gutted Iraq’s health-care system, and the 2003 invasion further damaged the country’s medical facilities and hollowed out the ranks of its medical personnel. Today, Iraq’s entanglement in hostilities between Iran and the United States will make it harder to cope with the pandemic. And a U.S. policy that continues to view the region primarily as a playground for its geostrategic rivalry with Iran will only worsen the impending disaster.
Several Iraqi doctors told me over the past month that they are facing an emergency on par with the crises under Saddam Hussein in the 1990s and at the height of the civil war from 2006–8. After Saddam invaded Kuwait in August 1990, the United Nations—led by the United States—imposed crippling sanctions on the country. Prior to the Gulf War, Iraq had imported 70 percent of its medical supplies. But under the sanctions regime, doctors were forced to halve doses of essential medicines or forgo administering drugs altogether. Hospitals fell into disrepair, health centers lacked stethoscopes and sterilizers, and medical equipment sat idle without replacement parts.
By the end of the 1990s, Iraq’s health-care budget had plunged from $450 million to $22 million, according to The Lancet. Doctors could no longer survive on meager state salaries, and they began to flee the country in droves. But the larger exodus of physicians came after the 2003 U.S. invasion, as Iraq sank into civil war. Militias targeted doctors suspected of having ties to the Baathist regime, and authorities failed to protect them. By 2006, 18,000 of the country’s remaining 34,000 doctors had fled the country. Around 2,000 were killed, and some 250 were kidnapped.
The U.S. invasion led to the physical destruction of 12 percent of Iraq’s hospitals, but it also gutted the ranks of medical personnel and public health officials. In their push for de-Baathification, U.S. officials fired many of the senior doctors and administrators who hadn’t already been run out of the country. Their replacements were often underqualified, winning their posts through connections; at its highest levels, the Ministry of Health became a vehicle for doling out patronage. Although the ministry’s budget increased from $16 million in 2002 to nearly $1 billion in 2004, very little of the money actually reached people who needed treatment. Instead, funds intended for health care ended up in fake or bloated agreements with Iraqi and U.S. contractors or in the hands of Iranian-backed militias. For example, Parsons Corporation, a U.S. company, received a $70 million contract to build 150 clinics but never completed them. (In a congressional hearing, when a member of Congress asked Parsons’s Iraq project manager if the company “should return some of its profits to the taxpayer,” he responded, “No, sir, I will not.”) By 2005, doctors described the Iraqi health-care sector as more corrupt than it was under Saddam. Many Iraqis traveled to countries such as India, Iran, Lebanon, and Syria for medical treatment rather than trying to seek it at home. As one Lancet study noted, “No longer can the health care in Iraq . . . be conceptualized as being confined to the borders of the state.”
Iraq's Ministry of Health became a vehicle for doling out patronage.
After decades of war and corruption, Iraqis no longer trust their medical system. In the UN sanctions era, Iraqis saw the underequipped hospitals as places where people went to die. Families lost faith in the ability of doctors to help their loved ones. And after the 2003 invasion, hospitals became battlegrounds; Shiite militias barged into hospitals and abducted Sunni patients.
Widespread distrust of the health-care system is already proving deadly in the current pandemic. Some families have refused to allow hospitals to quarantine their relatives. Others have gone as far as threatening to shoot doctors for trying to place family members in isolation wards. Reports suggest that some patients have run away after receiving a positive diagnosis for COVID-19. Doctors worry that one of the reasons that Iraq is seeing fewer cases than its neighbors is because many Iraqis refuse to enter the health-care system in the first place.
In Baghdad, authorities have established a task force to mitigate the spread of COVID-19, but there is no prime minister to lead and coordinate the efforts. Since former Prime Minister Adel Abdul-Mahdi resigned last November, after weeks of mass protests, the wrangling political blocs have been unable to agree on a replacement. Two proposed candidates failed to win broad support, because they were seen as too close to either Iran or the United States. A third candidate, Mustafa al-Kadhimi, the head of the National Intelligence Service, was nominated in early April but has yet to be confirmed. In the absence of clear political leadership, the response to the pandemic has been uneven and confused. Although the task force imposed a curfew and shut borders, arbitrary internal travel restrictions have stopped health workers from crossing into different governorates to deliver supplies or provide treatment.
Iraq continues to serve as a battleground in the proxy war between Tehran and Washington, which escalated to the brink of open conflict in January after the administration of U.S. President Donald Trump killed Qasem Soleimani, the commander of the Iranian Quds Force, in a targeted strike outside the Baghdad airport. Tensions flared again in March, when Iranian-backed militias attacked military bases in Iraq that housed U.S. troops.
These hostilities between Iran and the United States make Iraq even more vulnerable to the pandemic. Iran has experienced one of the worst outbreaks of the disease, but the Trump administration has refused to lift, even temporarily, the sanctions that it imposed on the country last year. The result, as Human Rights Watch noted, is that Iran has had limited access to the supplies and equipment necessary to treat COVID-19 patients. The United States has promised to veto Iran’s request for a $5 billion emergency loan from the International Monetary Fund to help fight the coronavirus. Sanctions don’t just hurt Iran’s ability to treat its own citizens—they also limit its ability to treat Iraqis, millions of whom travel to Iran for health care. And despite Iraq’s insistence that it has closed its borders, the nearly 1,000-mile border between Iran and Iraq is porous, informally open to religious pilgrims, businesspersons, and militias—and the spread of infection.
The Iraqi government’s entanglement in the U.S.-Iranian rivalry and its weak emphasis on public welfare will have dire repercussions. Without a strong prime minister to set the political agenda, Iranian-backed militia groups in Baghdad will continue to emphasize brinksmanship. The movement of soldiers and paramilitary groups across the region raises health risks. Even though several Iranian-backed militia members have tested positive for COVID-19, the paramilitaries continue to move between Iraq and Syria, leaving Iraqis, Syrians, and even U.S. troops vulnerable to the disease.
In the midst of the gravest public health crisis in recent history, U.S. officials must steer Middle East policy away from conflict, which will only compound the damage to public health infrastructure. Rather than increasing hostilities, the United States must work with Iran toward a humanitarian détente. If Washington does not take immediate action to de-escalate tensions in the region, beginning with freezing the sanctions on Iran and dialing down the proxy war, Iraq will struggle to contain the outbreak. In a nightmare scenario, Iraq might even become a reservoir of the virus from which a second wave of the pandemic might emerge.
Faced With a New Disease, Many in the Region See an Old Enemy