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ICG Risk Blog - [ Collapsing the Iraqi healthcare system: another attack on the extended supply chain that supports Iraqi government legitimacy ]

Collapsing the Iraqi healthcare system: another attack on the extended supply chain that supports Iraqi government legitimacy


Predation against the Iraqi health system is yet another progression in the Baathist-jihadist-criminal destabilization of the Coalition-Iraqi extended supply chain. It is instructive to review the progression from hard to increasingly softer targets. In Jihadists extend kidnapping and implied beheading down the coalition supply chain, August 2004, I noted:

Jihadists are nothing if not clever and inventive in their approach to asymmetrical warfare against the US -- and it is the US that is the ultimate target of the current kidnappings as it is the Snow White among largely coalition Dwarfs. The jihadist approach in both Iraq and Saudi Arabia has been to progressively move from hard to soft to softer targets, the latter made especially 'soft' by both physical and domestic political vulnerability… [J]ihadists and Feydayeen quickly withdrew from direct force on force confrontations [early] in the war, shifting to a guerrilla war mode that then shifted into an extensive use of [IEDs]. In short order. attacks extended to antipersonnel strikes on US commercial and contract security assets then, in Saudi Arabia, the attack profile shifted into the soft targets of civilian compounds and commercial office blocks while the attacks in Iraq shifted to nascent Iraqi defense forces and civil authorities.

In Beheadings as ascendant psywar against the periphery of the coalition supply chain, I extended the progression to:

Frighten American and other foreign nongovernmental groups and civilian contractors -- truck drivers and barbers just as much as translators and security personnel -- that complete the extended supply chain that supports US operations in country.

Larry Diamond's What Went Wrong in Iraq is useful in pointing out the lapse of security as the singular instrument by which Baathists and their allies achieve their aims:

In postconflict situations in which the state has collapsed, security trumps everything: it is the central pedestal that supports all else. Without some minimum level of security, people cannot engage in trade and commerce, organize to rebuild their communities, or participate meaningfully in politics. Without security, a country has nothing but disorder, distrust, and desperation-an utterly Hobbesian situation in which fear pervades and raw force dominates.

Diamond notes that four basic components (political, economic, social reconstruction, and security) are required to rebuild a nation rent by war:

political reconstruction of a legitimate and capable state; economic reconstruction, including the rebuilding of the country's physical infrastructure and the creation of rules and institutions that enable a market economy; social reconstruction, including the renewal (or in some cases, creation) of a civil society and political culture that foster voluntary cooperation and the limitation of state power; and the provision of general security, to establish a safe and orderly environment.

The interactions of these components continue to play out in Iraq much as Diamond described them in 2004:

Without legitimate, rule-based, and effective government, economic and physical reconstruction will lag and investors will refuse to risk their capital to produce jobs and new wealth. Without demonstrable progress on the economic front, a new government cannot develop or sustain legitimacy, and its effectiveness will quickly wane. Without the development of social capital-in the form of horizontal bonds of trust and cooperation in a (re)emerging civil society-economic development will not proceed with sufficient vigor or variety, and the new system of government will not be properly scrutinized or supported. And without security, everything else grinds to a halt.

In Forecast for Iraq and Afghanistan: taking the pulse of the war on terrorOctober 2004, I noted that Baathists are in a marriage of convenience with the jihadists - and with criminal and opportunist groups for that matter - as Baathists seek to regain control in a "third coup" (previous ones being 1963 and 1968). I agree with Kenneth Katzman that "former Baathists [are] waiting until the political process fails and Iraq becomes further destabilized. They will then emerge--perhaps violently--and present themselves as the only solution to the nation's security problem." Should the Baathists achieve that victory, they will make short work of the jihadists as well as criminal elements not of use to them.

As part of that commentary, I observed that:

Sunni insurgents will hammer away at the thin supporting infrastructure of cooks, drivers, barbers, and translators, not to mention the security forces -- who, by the way, primarily take up this line of work because the economy has collapsed and there are no jobs to speak of.

It should be remembered that one ubiquitous and critical provider of 'soft' health and human services in a societal reconstruction, the United Nations, was driven from Iraq in 2003 when, in what was a massive blow to the UN organization and to Kofi Annan personally, the UN High Commissioner for Human Rights, Sergio Vieira de Mello, on special assignment to Iraq with a crack team to establish UN services was killed when the UN headquarters in the Canal Hotel was destroyed by a suicide bomber.

Attacks on the private Iraqi healthcare system, once one of the best in the Middle East, in concert with infrastructure attacks on the electricity and water systems and supply interruptions of drug and healthcare commodities have now turned it into one of the most perilous:

In the past year, about 10 percent of Baghdad's total force of 32,000 registered doctors - Sunnis, Shiites and Christians - have left or been driven from work… The exodus has accelerated in recent months [with a] vast majority of those fleeing [being] the most senior doctors… the people who make the doctors, heads of departments… The exodus of senior doctors has resulted in very unpredictable medical service… Patients are not sure whether they will find their doctors. Junior doctors fresh out of medical school are performing complicated surgical operations that ordinarily would be done by more experienced doctors.

Hiwa Osman recently made a thoughtful analysis of the symbiotic cooperation among Iraqi factions and the fear that they impart to the extended Iraqi supply chain, health care included. The health care debacle strikes at the most personal level.

Unless the US and its Iraqi government counterparts can regain and "hold a monopoly on the use of violence," we may again see "one more violence-ridden [society turning] to almost any political force that promises to provide order, even if it is oppressive."

Facing Chaos, Iraqi Doctors Are Quitting
New York Times
May 30, 2005

IRAQ: Insurgency Goals
Council on Foreign Relations
Updated: May 20, 2005

What Went Wrong in Iraq
By Larry Diamond
Foreign Affairs
September/October 2004

Gordon Housworth

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