Iraq, determination to ignore?

The WHO_Iraq MoH have finally published on Sept 16 a summary report of part of the study conducted as ex-post assessment of prevalence of birth defects, still births, miscarriages, through an household survey. The report begins with a quite “derogatory” definition as “anecdotal” for any other study done in Iraq (few) but a review paper on DU, by local doctors.

This is beginning remark of the report is worth to be underlined, as it was unnecessary of them and inappropriate to the matter. None of the quoted study had the pretense of being a prevalence or incidence study, yet they were not anecdotal, but rather analytical or genetic studies of a selected group of families with birth defects. They exposed contamination of families by metal elements with potential teratogen and carcinogen effects and family presentation of birth defects without familiarity, sporadic.

As already noticed on September 10, in this BMJ blog, the design of the WHO-MoH experiment was thought in the “awe of finding correlation with  exposure to DU”. The only study the report mentions as credible is a review specifically dedicated to DU impact on reproductive health, which contained no referred references, nor papers available for a wider community, of prevalence studies done in Iraq and concluded that there is no ground for assuming DU is dangerous.

So in this “awe”, and not very scientific, mood, the WHO-MoH study avoided requesting information about any environmental exposure, with the exception of clinical X ray, and did not consider any other of the complex post war remnants and situations that could affect the presentation of birth defects.

Nonetheless it did not present information to prove that there was a familiarity in the people with birth defects investigated (the father side of the family is completely ignored).

The truth is that there is not only DU but a whole number of other potential long term persisting contaminants derived form war, and there are war-related damages that are candidates for causing reproductive damages; blindness to see that life style and resources in Iraq are not “untouched” by its decades long history of sanctions biting the nutritional level and health care, attacks by multiple weaponry and destruction of infrastructures, is not a good sound view for a scientific-public health perspective. But here it was resolved  to “choose to ignore”, by not asking, nor there were objective data to support the choice of where to localize the study.

The WHO-MoH study, could have better obtained data of present incidence of birth defects within maternities, as they acknowledge themselves, and employed the numerous and qualified staff they had for this aim; they could have obtained family histories from the women delivering in Hospitals in 2012 in order to reconstruct the pattern in the past. In addition they could have left, as side product, trained personnel in the some Hospitals to continue the registration.

Is legitimate doubting also because is known that the MoH in Iraq had presented already by the end of 2010 a questionnaires to maternities for registering birth defects. Why not then this WHO-MoH study did not assist its implementation and collected data of incidence?

Why to chose an household survey instead? A questionable choice per se, since in general it poses possibilities of giving a biased picture.

Specifically here, there are other difficulties in evaluating the meaning of the results of such survey.

Question arise because none of the criteria used for the initial selection of the areas is documented; the “criteria determined by MoH to define the areas as exposed to bombing or heavy fighting or not” are not identified, e.g. referring to chronology, mapping and type of event by UN or Government, or by data of detection of war-remnants.

In addition it is not clear how, within these districts, the individual clusters were defined (I am assuming that census enumeration areas correspond to neighborhoods) from which randomly then individual households were chosen.

These choices are absolutely in need to be clarified, because of the relevance they have in determining the outcome of the study, to convince about the soundness of their rationale. They eventually determine also the “numbers” obtained.

Given that the study manifests clearly a core prejudice in denying any interest to seek potential effectors for the birth defects, and implicitly declines thus also any concern for being useful for public health, it is legitimate to ask if it was designed assuming that one way to avoid rising the issue of environmental effector and public health intervention could be choosing “adequately” the areas for survey.

In addition, it would have been routine in any other country to pose questions about exposures to pesticides, new industrial sites, adjacency of housing to waste and  sewage plants, open discharges,  as should have been in the specific case of Iraq to ask also about war events, petrol fires, past-present malnutrition, use of gas.-fed generators and other environmental factors that are commonly found after wars and destruction of structures of all kinds. Would have been essential also to have asked the residential history of the households.

In a previous letter about this project I already criticized the design of the survey as inappropriate to acquire information in the circumstances and not aimed to provide for the future public health.

I reaffirm that an answer should be given to the criticisms after their work was published, and that the suggestion to finish the study acquiring historical residence and exposures of the cases should be accepted..

Completing the study will at least reveal more of the soundness of the criteria for selecting the households and about the correctness of inclusion.

Important to underline is that, for some of the potential effectors for reproductive health impairment there may be ways to study remediation for affected populations.

We and Iraqi have been deprived of this chance of going ahead in this direction, while possibly a lot of energies and unknown quantities of money were spent to discover that, after all, a war does better for reproductive health than western life standards (3% birth defects and in rise industrialized areas, some prevalence of still births and abortion, roughly), a recommendation for continued health that should cheer up the “next population to be served with a combination of sanctions-attacks-occupation” treatment and those that already got the some cocktail.

This report, by its omissions, amounts to freezing and normalizing a situation that, at least in more than one sizable hot spot in the country, emerges as being quite different, observationally;  avoidance of getting insight in the observational reports  by ignoring to go and investigate exactly were they come from, is not a good omen for the usefulness or even the transparency of purposes of the study.

Avoiding to study the critical areas and using unclear criteria of area selection and using household survey, can “normalize” a situation and segregates into invisibility  the areas and people more severely in need.

We need to be convinced therefore, await for the comments to this criticisms and other criticisms that may arrive, await to know about a correction of the line of work of WHO-Moh, in their follow up studies.

By Paola Manduca, Prof.Genetics, University of Genoa, Italy