Determined to ignore reality? Questions that the Iraqi Ministry of Health-WHO report didn't ask
By Paola Manduca, Professor of Genetics at the University of Genoa, Italy
Iraq's Ministry of Health and the World Health Organisation have published a summary report of ex-post assessment of the prevalence of birth defects, still-births and miscarriages in the country obtained through a household survey. Before publication of the report, I criticised in the British Medical Journal (Rapid responses, September 10, 2013) the design of the survey as inappropriate. Post-publication, clarification of the points I raised was necessary and action to finish the study acquiring historical residence and exposure of the cases should be accepted by the MoH in Baghdad and the WHO, and is feasible. Completing the study with clarifications and these data will show its relevance and pitfalls more clearly.
The study was designed with an inbuilt prejudice of "not wishing to investigate correlation with exposure to depleted uranium"; not very scientific. The MoH-WHO study didn't request information about all environmental exposures and did not consider any other of the complex post-war detritus and situations that could affect reproductive health.
It is not only DU that is a potential teratogen or foetal toxicant; there are a number of other potential long-term and persisting contaminants derived from war as well as war-related candidate-enhancers of reproductive damage. Removing one's self-imposed blinkers is necessary to see that life style and resources in Iraq are not "untouched" by its decades-long history of sanctions which have hit nutritional levels and health care; attacks by varied weaponry; and the destruction of the country's infrastructure. To ignore or overlook these factors is not sound from a scientific-public health perspective. However, in the Iraqi MoH-WHO study there appears to have been a resolve "to ignore" by simply not asking. The study was also inept to investigate proofs of familiality in the couples with birth defects investigated; the father's side of the family was ignored completely.
Consistent with its determination to ignore reality, and instrumental in enforcing it, the report began with a derogatory dismissal as "anecdotal" of the few previous studies except one, which the MoH-WHO described as "credible". It reviews the impact of DU on reproductive health, referring to information unavailable to the wider scientific community, of the prevalence of birth defects and concluding that DU was not a risk factor for reproductive health.
Apparently, it was necessary to discredit other studies (analytical or genetic studies of a selected group of families with birth defects) which showed contamination of families by metal elements with potential teratogen and carcinogen effects, and frequent presentation of birth defects without familiality. Dismissing and discrediting, rather than disproving by research, is inappropriate scientifically and unconvincing ethically.
To choose a household survey as the basis of a study is a questionable choice per se; it generates possibilities for giving a biased picture. No rationale was given and none of the criteria are documented for the initial selection of areas in which the study was conducted. Previous data were alluded to, as the grounds for these decisions, but the "criteria determined by the MoH to define the areas as exposed to bombing or heavy fighting or not" are not identified; for example, referring to chronology, mapping and type of event by UN or government, or by data of detection of war-detritus.
In addition it is not clear how, within the districts chosen, individual clusters were defined from which individual households were selected at random. These choices need to be clarified to show the soundness of their rationale because of the relevance they have in determining the outcome of the study and the statistics obtained.
Given the clear "prejudicial denial of interest" of the study to seek potential war-related factors for the birth defects, it is legitimate to ask if one way to avoid raising the issue of environmental factors could have been choosing the areas for the survey more carefully.
The MoH-WHO study could have obtained the data relating to the incidence of birth defects within maternities more effectively, as the report's authors eventually acknowledge. It is known that Iraq's Ministry of Health had by the end of 2010 started to use a questionnaire in hospitals to register birth defects.
The numerous and qualified staff hired for this survey could have registered incidence levels and obtained family and residential histories from the women delivering in hospitals in 2012 in order to reconstruct the pattern of reproductive damage in the past. Working in hospitals could have had the added benefit of leaving such personnel trained to continue birth defect registration, a goal in itself for public health. Why then did the Iraq MoH-WHO study not help the implementation of the registration process with its potential for collecting valuable data?
It would have been routine in any other country to pose questions about exposures to pesticides, new industrial sites, proximity of housing to waste and sewage plants, open discharges, et cetera. In the specific case of Iraq, it should have been routine to ask about war incidents, petrol fires, past and present malnutrition, use of diesel generators and other environmental factors that are found after war and the destruction of national infrastructure. It would also have been essential to ask the residential history of the people interviewed.
As it is, this report amounts to the normalisation of a situation that, in more than one hot spot in Iraq, has emerged as worrying, observationally; it also ignores the proofs of high environmental contamination produced by research studies. The avoidance of getting an insight into the observational reports on the contamination of the population by simply dismissing them, rather than investigating the places where these reports originated, is not a good omen for the usefulness or even the transparency of purposes of the Iraq MoH-WHO study. Avoiding investigation of critical areas and an "undocumented choice" of household survey can "normalise" a situation and pushes into invisibility the areas and people more severely damaged. As such, we have not been offered elements to validate the soundness of the Iraq MoH and WHO study scientifically, and await comments from the two bodies.
We need a genuine commitment to provide a sound scientific basis, transparency in the team and preliminary protocols before undertaking, as announced, any follow-up or new studies of this kind. In addition, we need to warn that any option that may exist to repair the damage in affected populations has to be based on the identification of the potential factors for damage to reproductive health; investigations should be directed to assess, or dismiss, the reported contamination of the section of the population of reproductive age and their progeny.
As scientists and doctors, as with the Iraqi people, we were deprived of the chance of working towards remedies as a great deal of energy and an unknown amount of money has been spent on this study to "discover" that, against all the odds, a war after sanctions has an even better impact on reproductive health than life with western standards (with a similar prevalence of birth defects and a lesser prevalence for still-births and premature child loss).
This report looks suspiciously like official "reassurance" for the next country to be served-up with the sanctions-attacks-occupation treatment, as well as those already in receipt of the same lethal cocktail.
Published on the Middle East Monitor