write an essay describing what was discussed in the publication

The Maladies of Water and War: Addressing Poor Water Quality in Iraq

Water is essential in pro-

viding nutrients, but contam-

inated water contributes to

poor population health.

Water quality and availabil-

ity can change in unstruc-

tured situations, such aswar.

To develop a practical

strategy to address poor

water quality resulting from

intermittent wars in Iraq, I

reviewed information from

academic sources regarding

waterborne diseases, con-

flict and war, water quality

treatment, and malnutrition.

The prevalence of disease

was high in impoverished,

malnourished populations

exposed to contaminated

water sources.

The data aided in develop-

ing a strategy to improve

water quality in Iraq, which

encompasses remineralized

water from desalination

plants, health care reform,

monitoring and evaluation

systems, and educational

public health interventions.

(Am J Public Health. Pub-

lished online ahead of print

April 18, 2013: e1–e7.doi:10.

2105/AJPH.2012.301118)

Tara Rava Zolnikov, MS, ScM

A LONG HISTORY OF UNSTABLE

rule, border disputes, and religious strife has created continuous con- flict in Iraq, with wars conducted from the beginning of the 20th century to the present. Iraq took part in World Wars I and II. The Persian Gulf wars had three phases: 1980 to 1988, 1988 to 1991, and 2003 to 2010.1,2 The American involvement in Iraq and Afghanistan represent the most sustained combat in the world since the Vietnam War.3

War causes worker shortages, skill-set imbalances, and unreli- able distribution of supplies.4

Unstable leadership, disputed territory, and degradation of land and supplies lead to various pub- lic health challenges, which Iraq has experienced throughout the past century.5 Iraq’s geography exposes inhabitants to significant threats of waterborne and infec- tious diseases because of the construction of cities along the Tigris and Euphrates rivers and the proximity to neighboring ter- ritories that have frequent disease outbreaks. In the mid-20th cen- tury, during a hiatus between World War II and the Persian Gulf wars, Iraqis enjoyed com- prehensive health care services, including modern hospitals, throughout the country. By 1992, most hospitals were oper- ating at a fraction of their pre- vious level and faced severe medical and supply shortages. Health care access declined and disease proliferated. Malaria, cholera, gastrointestinal diseases, and typhoid fever became preva- lent throughout Iraq.

Another effect of war in Iraq is infrastructure deterioration. The destruction of Iraq’s water supply system caused widespread failure of water purification and sewage systems.5 Public health issues became secondary to fundamen- tal human needs; Iraq has be- come a developing country whose people suffer decreased access to clean water, increased prevalence of malnutrition, and heightened severity of disease outbreaks.

Research regarding practical strategies to address Iraq’s water crisis is sparse and outdated. The most recent article on the United Nations (UN) Educational, Scien- tific, and Cultural Organization’s Web site concerning water in Iraq was published in August 2010.6

I evaluated water quality issues in Iraq, beginning with a review of historical and current accounts of waterborne disease outbreaks resulting from war. My aim was to amass information on sustainable water quality measures to use in preventing and mitigating disease outbreaks resulting from poor water quality in Iraq. Useful knowledge includes historical and current data on waterborne dis- eases, best practices for rebuilding war-torn societies, nutritional sta- tus of the population, public health infrastructure and awareness, and the country’s overall economic and political state.

REVIEW

I searched multiple search en- gines (PubMed, Web of Science, ScienceDirect) with the terms

“water,” “Iraq,” “war,” “diseases,” “outbreaks,” and “public health” for peer-reviewed journal articles. These articles discussed wars in Iraq, historical accounts of dis- ease outbreaks in Iraq, water in war-torn societies, desalination, and general water nutrition. I excluded studies that primarily focused on public health in the developed world, developed world interventions, and conflict- free zones.

I contacted experts in water quality and pollution, global health interventions, and nutrition to seek opinions on appropriate solutions to water quality prob- lems in Iraq. I carefully reviewed and categorized this information.

I focused solely on disease oc- currences from exposure to poor water quality in the war-torn so- ciety of Iraq and did not specifi- cally address other environmental exposures or contamination issues, psychosocial responses, additional effects of war, health outcomes, or disease outbreaks that were not attributable to waterborne expo- sure. I assumed that the public health infrastructure and current economic status of Iraq were operational and stable.

Quantitative and qualitative re- search in conflict areas is sparse because of the difficulty of col- lecting data and because more urgent needs often take prece- dence; information from the me- dia and nonprofit organizations often lacks a scientific basis or is unpublished. For these reasons, the search may have missed some information, limiting my ability to fully analyze this issue.

CRISES AND OPPORTUNITIES

Published online ahead of print April 18, 2013 | American Journal of Public Health Zolnikov | Peer Reviewed | Crises and Opportunities | e1

WATER, NUTRITION, AND DISEASE

Water is the most abundant compound on earth and is essen- tial for life. It exists in liquid, solid, and gaseous states. Water is an essential nutrient for proper maintenance of homeostasis in the human body.7 Humans ingest water through drinking (water and other beverages), eating, and me- tabolism of food. Water has been referred to as the universal solvent because it can dissolve more sub- stances than any other liquid.8

This solvent nature allows water to contain both harmful and ben- eficial substances.9

Twenty-one elements in water are known to be essential for human health. These include po- tentially anionic groups (chlorine, phosphorus, molybdenum, fluo- rine), cationic forms (calcium, magnesium, sodium, potassium, ferrous iron, copper, zinc, manga- nese), nonmetal covalent com- pounds formed metabolically (io- dine, selenium), and ions (boron, chromium, nickel, silicon, vana- dium). Fourteen elements are es- sential for bone and membrane structure, water and electrolyte balance, metabolic catalysis, oxy- gen binding, and hormone func- tion. Adverse health effects from depletion of these elements in- clude increased morbidity and mortality.9

Although water supplies are highly variable, drinking water supplies usually contain many of these essential minerals, either naturally or deliberately added. The enteric absorption of minerals from drinking water depends on the properties of the minerals and their reactions, the physiological conditions of the gut, the amount of consumption, and additional factors related to diet, including which minerals are ingested.9

Nonnutritional, toxic elements in- clude lead, cadmium, mercury, arsenic, aluminum, lithium, and tin.

The Institute of Medicine rec- ommends approximately 2.7 liters of total daily water for women and 3.7 liters for men. In the devel- oped world, 80% of the popula- tion’s total water intake is from potable water and other bever- ages, and 20% is from food. In- creased daily water needs may arise from increased exposure to humidity or aridity, elevated tem- peratures, or physical activity.10

The effect of water’s nutritional status may be relatively minor in comparison to other burdens of disease, but nutrients in water can significantly affect human health in a variety of ways. Calcium and magnesium are important for bone and cardiovascular health, fluoride prevents dental caries, sodium is needed to maintain electrolyte balance, and copper and selenium are important for antioxidant function. Copper is also a key component for iron utilization and promotes cardio- vascular health. Potassium is es- sential in the control of heart rate, muscle contraction, energy levels, and nerve impulses. Chronic in- adequate intake of dietary calcium can result in hypocalcemia, body numbness, tingling in fingers, muscle cramps, convulsions, leth- argy, anorexia, abnormal heart rhythms, osteopenia, osteoporosis, increased risk of bone fracture, and rickets.11,12 Magnesium defi- ciency can manifest as loss of appetite, nausea, vomiting, fatigue, body numbness, tingling, muscle contractions and cramps, seizures, personality changes, abnormal heart rhythm, coronary spasm, hypocalcemia, or hypokalemia.13—17

Fluoride aids in the retention of calcium and strengthens teeth and bones; fluoride use in caries prevention efforts significantly

reduces dental carries in the ma- jority of populations.18,19

Because of their major contri- butions to human health, it is of the utmost importance that these elements be consumed in the daily diet.9 When the average intake of minerals is below recommended levels, they can be added to the water supply.

The ability of water to dissolve substances and redistribute them widely can cause adverse health effects in exposed populations. Water can carry environmental toxins such as mercury, arsenic, lead, cobalt, cadmium, petroleum products, oil, soot from oil fires, and depleted uranium.20,21 Harm- ful waterborne bacteria include Salmonella typhi, Salmonella para- typhi, and Vibrio cholerae; other infectious agents are the virus hepatitis A and vector diseases transmitted by Plasmodium falci- parum and Schistosoma hematobin.

Malnutrition is the most com- mon cause of immunodeficiency worldwide. It may be associated with significant impairment of bone growth, electrolyte balance, antioxidant function, iron utiliza- tion, cell-mediated immunity, phagocyte function, the comple- ment system, and cytokine pro- duction. Deficiencies of 1 or more nutrients can alter immune re- sponses, even if the deficiencies are relatively mild.22

Water concerns remain among the most significant international public health issues. Approxi- mately 11% of the world’s popu- lation (780 million people) lack access to safe or affordable drink- ing water, and 2.5 billion people have inadequate access to sanita- tion services.23 In 2001, approxi- mately 4 million people world- wide died from waterborne diseases.24 In 2002, the World Health Organization estimated that 4 million deaths annually

were attributable to water-related diseases such as cholera, hepatitis, dengue fever, malaria, and other parasitic diseases.9 Inadequate fruit and vegetable intake, water sanitation, and hygiene are the main factors contributing to mor- tality in the developing world.25

During wartime or other con- flicts, water supply systems are vulnerable to disruption. Destruc- tion of water supply infrastruc- tures (e.g., water mains and treat- ment facilities), deliberate dis- connection of power stations and power lines to water stations, and disruption of the operation and maintenance of water supply systems are among the tactics combatants may use.24 Poorly managed military waste has con- tributed to the spread of disease and is a major contributor to the contamination of drinking water.15

When access to normal civilian water supplies is disrupted, people may be forced to collect water by unhygienic means, with resultant health consequences.24 During times of social disruption, hazard- ous pathogens can more easily colonize populations. Historically, devastating plague outbreaks oc- curred concurrently with cold, wet weather and depressed agriculture production.26

HISTORICAL WATER QUALITY AND DISEASE IN IRAQ

Iraq became a sovereign king- dom in 1932, after fighting for more than 12 years to free itself from British control.27,28 In 1958, a republic was proclaimed, al- though a single leader did not remain in power for long and the country was continually entangled in territorial disputes and wars.28

Transport of water in Iraq is limited, so historically, potable water was plentiful in townships

CRISES AND OPPORTUNITIES

e2 | Crises and Opportunities | Peer Reviewed | Zolnikov American Journal of Public Health | Published online ahead of print April 18, 2013

and scarce in desert regions. Wa- ter was obtained from streams, springs, and wells or taken from rivers, canals, or lakes. Well water quality varied by location: wells in mountain regions were high in mineral content, and those in the lower delta were brackish. In rural Iraq, water was of poor quality, highly polluted, and untreated. In the country as a whole, only a small percentage of domestic water supplies were treated by chlorination and sedimentation. The majority of well and water- hole sources were grossly polluted and contaminated.27 By contrast, the city of Basrah took river water from Shatt al Arab, treated it by filtration and chlorination, and piped it to individual houses and community taps.

Government health services performed bacteriologic examina- tions throughout the country. Construction of the Hindiyah dam, beginning in the late 19th century, allowed irrigation of thousands of acres of newly productive agri- cultural areas. The country con- structed a reservoir for the storage of flood water in 1952.

By 1954, sewage disposal fa- cilities were still generally primi- tive, and cesspits were common. Modern government buildings and homes employed water car- riage systems to dispose of sewage in dumping grounds on the out- skirts of towns. Collection of sew- age through public facilities did not exist; instead, housetops, courtyards, and other convenient sites often served as latrines. These unsanitary practices en- couraged the spread of pollution in soil and water supplies.

Historically, the most com- monly reported diseases endemic to the Middle East were diar- rhea, hepatitis, schistosomiasis, and leishmaniasis; the majority of the reported diseases were

waterborne.29 Throughout Iraq, typhoid, paratyphoid, dysentery (ameobic and bacillary), diarrhea, cholera, enteritis, trichuriasis, en- terobiasis, and strongyloidiasis frequently occurred (Table 1).27,30,31

In the early 1950s, contami- nated food and water supplies, flies, and other unsanitary condi- tions caused intestinal diseases in Iraq. Enteric fevers were endemic. Typhoid fever affected about 70% to 80% of the population. Out- breaks peaked in the summer months. Dysentery (amoebic and bacillary) was widespread. Amoe- biasis occurred in Basrah, 60% to 70% of the population in Iraq harbored Endamoeba histolytica, and liver abscesses were common. Diarrhea and enteritis were major causes of illness and death in children. Giardiasis was common, as were salmonella food poisoning outbreaks. Cholera outbreaks fol- lowed in the wake of human travel, such as along the overland route to Mecca. In 1947, immu- nizations against cholera were compulsory for all travelers en- tering the country, as well as for the population along the Syrian frontier.27

Unprotected shallow wells or springs and poorly constructed homes lacking screens or closures

for windows exposed vulnerable human populations to vector- borne diseases. Schistosomiasis was a major public health issue in 1954; concern arose that disease might spread throughout the country with expanded irrigation. Unsanitary customs, such as using canals and other convenient bod- ies of water for religious ablutions and bathing, allowed further spread of schistosomiasis. The disease was prevalent among chil- dren and agricultural workers. Malaria broke out sporadically throughout Iraq, with varied se- verity. Regional rates ranged from 26 to 266 cases per 1000 pop- ulation. The inhabitants of Basrah had infectious spleen rates of ap- proximately 75% in 1941; the rates decreased to 12% in 1949 after implementation of control programs. Ancylostomiasis was present throughout the popula- tion, although the exact distribu- tion and severity of the infection was unknown. Infection rates were believed to be around 40% in the southern regions of the country. Ascariasis, enterobiasis, trichuriasis, and strongyloidiasis were prevalent but randomly dis- tributed, depending on customary food consumption. In 1952, the government of Iraq, along with the World Health Organization,

developed a rural health malaria control project.27

Health infrastructure signifi- cantly improved from the 1970s into the early 1980s; infant mor- tality rates decreased from 80 to 40 per 1000 live births, and under-5 mortality rates decreased from 120 to 60 deaths per 1000 population.9 From 1980 to 1988, Iraq was at war with the Islamic Republic of Iran. The war and political and economic sanctions resulted in the deterioration of public health and health system infrastructure and capacity and the health status of the population.

Health indicators revealed the rapid decline among Iraq’s popu- lation: in 1997, the prevalence of malnutrition was 24.7%; chronic malnutrition, 27.5%; and acute malnutrition, 8.9% among children younger than 5 years.32,33

Waterborne diseases followed degradation of water purification and sewage treatment plants; more than 1000 cholera deaths were reported in 1972, 1980, 1985, and 1989 and almost yearly from 1991 to 1999.34 The Iraqi Child and Maternal Mortality Survey found that diarrhea was the leading cause of death in infants from 1994 to 1999; it was responsible for 49.8% of infant mortlaity dur- ing this time.35 Malaria rates were

TABLE 1—Incidence of Waterborne Diseases in Iraq, 1923–2010

Disease

After World War I,

1923–1931, No.

After World War II,

1944–1950, No.

After Persian Gulf War I/II,

1990–1998, No.

Persian Gulf War III,

2005–2010, No.

Typhoid 559–842 36 208

Paratyphoid 97–230

Dysentery 180–1100

Diphtheria 1378

Cholera 1500–2500 4697

Gastrointestinal diseases 17 000–30 000 584 204

Schistosomiasis 15 800–27 300 1500

Malaria 598 800 98 705

Note. Estimates, not adjusted for population, derived from reported cases.27,30,31

CRISES AND OPPORTUNITIES

Published online ahead of print April 18, 2013 | American Journal of Public Health Zolnikov | Peer Reviewed | Crises and Opportunities | e3

significant in 1994; rates of schis- tosomiasis peaked in 1990.34,33

CURRENT WATER QUALITY AND DISEASE IN IRAQ

Poor water quality persists throughout Iraq. Hazardous chem- icals, including carbonates, sulfates, chlorides, and nitrates, have been discovered in multiple sources. Much of the drinking water is laden with high levels of toxic minerals, suspended solids, and salinity. Many groundwater sources of drinking water are brackish or contain excess saline. In Basrah, salinity levels are higher than 7000 parts per million; the World Health Organization standard for human consumption is less than 500 parts per million. River water surround- ing Basrah contains sewage, pol- lutants, and harmful bacteria.36

Pollution of the Tigris River is caused by industrial plants located on river banks. It is estimated that 60% of Iraq’s industrial facilities do not have functioning water treatment facilities for wastewater.37

Chlorophenols have been mea- sured in both the river and drinking water reservoirs, demon- strating that water treatment plants are not implementing ade- quate sterilization or purification processes.38 Petroleum residues and hydrocarbons have been measured in the Shatt al-Arab surface area of the water column. These petroleum residue wastes originate from a variety of crude oil sources.39 Spills and leaks of petroleum products are relatively common, and such incidents may lead to high concentrations of total petroleum hydrocarbons.9 Unre- fined and refined petroleum products contain various toxic substances. Aliphatic hydrocar- bons containing nitrogen and sul- fur, methane, heptane, or other

molecules may be dissolved or suspended in the mixture. Large doses of hydrocarbons can be neurotoxic. Aromatic hydrocar- bons include benzene, toluene, and benzopyrene; benzene is a known carcinogen.9 Last year, an Iraqi news article reported an oil spill outside Basra where ap- proximately 300 tons of oil drained into 22 kilometers of the Bada’a channel in 2011.40

Wartime encourages a shift in focus from future opportunities to current unstable situations and unmet needs.41 In 2011, UNICEF reported that 20% of the general Iraqi population and 40% of rural citizens did not have access to safe drinking water; 66% of the gen- eral population had access to waste collection services, but 92% of rural populations lacked them and 17% of the Iraqi population did not have access to adequate sanitation services.42 The UNICEF report assumed that the majority of adversely affected populations were rural.

Basrah remains the most neglected area in Iraq, with signif- icant rates of diarrhea and infec- tious disease. However, the health status of the population has im- proved considerably since 1990, when multiple invasions had dis- rupted health care. Public health funds were decreased by 90%; 1 in 3 clinics and 1 in 8 hospitals were looted or vandalized. Life expec- tancy rates fell to below 60 years for both men and women.41 The conflict of 2003 destroyed 12% of Iraq’s hospitals. Collapsed sanita- tion and water infrastructure led to an increased incidence of cholera, dysentery, and typhoid fever.43

Disease rates continue to in- crease throughout Iraq (Table 1). Typhoid fever is endemic. In 2005 to 2007, extreme weather and interrupted electricity in wa- ter supply units caused significant

outbreaks of typhoid fever, with the peak incidence in 2007.31 In the same year, a cholera outbreak spread rapidly throughout 60 percent of the country.

In 2004, substantial interna- tional funding provided tempo- rary improvement in Iraq’s public health situation; 240 hospitals and 1200 primary health centers were built and began operating. One year later, sanitary conditions in hospitals were unsatisfactory, trained personnel were absent, medical supplies were unattainable, and rural populations still lacked access. Health declined and disease rates continued to increase.43

FOUNDATIONS FOR CHANGE

War-torn societies face many large-scale economic, social, and political challenges. Deficiencies in accessible health care, public health infrastructure, and aware- ness contribute to the deteriorat- ing health of the Iraqi population. Infectious diseases increase with poor sanitation, limited access to clean water, and general malnu- trition.41 Long-term damage to water treatment facilities remains unrepaired.41 Electrical shortages continue to cause operational in- efficiencies, while services to dis- placed populations are hampered by shortages of equipment and machinery.42 Technical personnel and administrative officials are needed to improve overall regu- lation and standards of water ser- vices, and public health awareness efforts need to reach a larger audience.42

To establish a solid foundation for positive change in Iraq, primary issues of water quality, sanitation, and waste disposal need to be ad- dressed. Standard water treatment requires clarification, filtration, pu- rification, and desalinization, as

well as routine maintenance and testing for nutritional value, with supplementation when needed.36

Achievement of a healthier envi- ronment in Iraq will require public health reform, infrastructure re- building, and sustainable water quality techniques (Figure 1).

Current programs are address- ing water quality throughout Iraq. The UN Food and Agriculture Organization supports the Minis- try of Water Resources and the government of Erbil through re- building infrastructure. The UN Educational, Scientific and Cul- tural Organization is conducting groundwater surveys that provide data on shortages and manage- ment of underwater aquifers. The World Health Organization and UNICEF are working to enhance the quantity and quality of water to underserved residential areas. The UN Settlements Program and UNICEF provide the Iraqi gov- ernment with water and sanitation functional reviews, along with models for reforming public-sector water and sanitation systems.44

These working models, along with other interventions, have potential for improving Iraq’s water quality and ameliorating its waterborne disease burden.

Health Care Reform and

Public Health Interventions

Public health must address not only current issues, but historical and anticipated challenges as well. The recent Brazilian health reform movement proved that rapid progress can be achieved in public health.45 If Iraq adopted the Bra- zilian health reform model, its health care delivery could signifi- cantly improve.

In Brazil, decentralization al- lowed municipalities to assume greater responsibility for health services management; this system enhanced and formalized social

CRISES AND OPPORTUNITIES

e4 | Crises and Opportunities | Peer Reviewed | Zolnikov American Journal of Public Health | Published online ahead of print April 18, 2013

participation in health policymak- ing and accountability. Health care reform in Brazil led to increased access to health care, universal coverage for vaccinations and prenatal care, enhanced public awareness of health as a right, and expansion of human resources and technology.46 Expansion of health care coverage and univer- sal vaccination and prenatal care, including nutritional supplemen- tation, reduce malnutrition rates and may decrease susceptibility to infectious diseases.

Rebuilding public health infra- structure requires attention to so- cial determinants of historical health deficits, availability of re- sources and funding, current needs, prevention of disease spread, and mortality rates, among many other factors. Strategies must be flexible, efficient, and in- novative to address issues as they arise.47 Private-sector enterprises are often more efficient and in- novative than governments and can provide financial aid and en- courage environmental and social sustainability.48 Investing in

human and social capital may spur sustainable economic growth; in- come transfers strengthen the coverage and effectiveness of nu- trition programs.45 Public—private partnerships are essential to sus- taining financial aid to impover- ished regions (e.g., employment through public institutions), re- building government capacity and medical infrastructure, and sup- porting the Ministry of Health. Military and humanitarian aid must be coordinated, while quantitative aid impact indicators can be used to measure the quality and effective- ness of programs.48 Examples of important interventions are moni- toring water quality, ensuring daily access to clean water, and provid- ing education about waterborne diseases, environmental contami- nants and exposures, and boiling water when needed. Media can disseminate water health messages to address acute problems.

Water Quality Development

and Monitoring Systems

Basic drinking water treatment comprises filtering particulates

and adding chemicals to treat pathogens; multiple processes clarify or remove large particles, aerate to promote oxidation, remove smaller particles through coagulation and sand filtration, and finally treat the water chemically. These processes ultimately provide pathogen-free water, prevent re- contamination of the distribution system, and minimize harmful byproducts. Some existing water treatment facilities throughout Iraq have been repaired by nonprofits, including Veterans for Peace and the US Army.49,50 Conclusive evidence about the actual func- tioning of these water treatment plants remains unavailable.

Another important aspect of waterborne illness prevention is home-based water treatment.51,52

A simple model developed by the Centers for Disease Control and Prevention and the Pan American Health Organization comprises point-of-use water treatment, safe storage of treated water, and community education. The model elements may be adapted to the needs of affected populations.51

Point-of-use water treatment focuses on simple household methods for cleaning water, such as boiling, bleaching, filtering through a cloth, sediment (sand and gravel) filtration, and ultravi- olet light disinfection; however, boiling water can be economically and environmentally unsustain- able in the developing world, and boiled water can easily be recon- taminated during transfer to a container and storage. Chemical disinfectants are expensive and most likely unsuitable for house- hold use. Solar disinfection in- volves a combination of ultraviolet radiation and thermal treatment, but the water may be recontami- nated during transfer. The annual total daily diffuse radiation (70.82 mg/m2) and value of clearness

index (KT) percentage of Baghdad (range = 65.9% in August to 48.4% in January) indicates the potential efficacy of solar disinfec- tant point-of-use water treatment in Iraq.53 Safe water vessels can be used in every process; these ves- sels store clean water and control recontamination.54 Storage tank openings should be less than 10 centimeters in diameter; this de- sign limits human exposure to the vessel’s contents.54

Integrated water resource man- agement addresses water quality concerns over the long term. Ei- ther governmental or nonprofit entities can monitor water quality. An interagency UN program en- courages water-related programs and projects through development assessment, management, moni- toring, and use of water sources by maximizing systemwide action through support and established targets and goals.55 Program ad- ministrators track implementation, develop necessary changes, and support water-related initiatives.55

Data on adaptations of established programs and program impact can inform organizations’ choices about change. Success in water re- source management is facilitated by communication between pro- gram administrators and beneficia- ries; such a working relationship allows parties to learn from one another and to respond effectively to changing conditions.56—58

Nutritional Supplements in

Water

In 1989, a nutritional survey conducted in Iraq determined that the distribution of the weight and height of children aged 8 years and younger was similar to that in the international reference popu- lation; Iraq had one of the highest levels of food availability per cap- ita in the region.59 Sanctions fol- lowing the Gulf wars caused

Water resource management

Water treatment facilities Re-mineralized desalination plants

Point of use water treatment

Health care reform Rebuilding public health infrastructure

FIGURE 1—Top-down approach to water quality reconstruction in

Iraq.

CRISES AND OPPORTUNITIES

Published online ahead of print April 18, 2013 | American Journal of Public Health Zolnikov | Peer Reviewed | Crises and Opportunities | e5

decreased food imports and a de- pressed economy. To this day, a large portion of the Iraqi popu- lation relies heavily on subsidized food prices; some foods are ra- tioned, but open markets are un- regulated.60,61 Approximately 1 million people in Iraq were classi- fied as food insecure in 2008.62

Current basic rations are largely composed of carbohydrates and are deficient in protein and most vitamins and minerals.61

Food is the principal source of nutrition, but water can also pro- vide beneficial dietary substances. Determining the true effects of water nutrition requires collection of data on composition and intake, nutritional factors under steady- state conditions, and water inges- tion rates, all of which may en- hance or decrease the importance of minerals in drinking water.9

Relevant health outcomes should be evaluated and compared with the nutritional statuses of vulner- able populations. In developing countries, where the average in- take of minerals is below recom- mended levels, nutritional supple- ments in water may help close that gap. Young children, pregnant women, older populations, immu- nocompromised, and malnour- ished people are more sensitive than the typical healthy adult to inadequate levels of essential dietary nutrients.

Desalination plants run the risk of contributing to malnutrition and increasing susceptibility to in- fections.9 Desalination removes salt and other minerals from salt water so that it can be used for drinking or irrigation.63 The de- salination process reduces virtu- ally all ions in drinking water; populations relying on this water source receive fewer nutrients, which may have a significant im- pact on health if regular diets do not provide sufficient nutrient

supplementation.9 If not properly stabilized, demineralized water can also corrode plumbing, thereby increasing the popula- tion’s exposure to metals, includ- ing copper and lead.

However, desalination plants can deliver clean water to popu- lations that have low-quality water or limited access to drinking wa- ter; the plants can also offer nutrient-rich water. Remineralized water adds beneficial nutrients to drinking water, of particular im- portance to malnourished popula- tions. Minimum amounts of cal- cium, magnesium, fluoride, and other essential trace minerals must be specified and heavily regulated within the plants. When desalination plants are contemplated as part of new or reconstructed water treatment facilities, remineralization should also be implemented.

According to an online Iraqi news source, 8 desalination plants opened in Basrah in 2010.64

Monitoring of the effects should report indicators of population well-being and disease rates. Data collection should include changes in population musculoskeletal and cardiovascular health and disease diagnoses and prevalence of den- tal caries to provide a complete assessment of the effects of nutri- ents in the water.

CONCLUSIONS

Because of its extraordinary ability to dissolve and transfer in- numerable particle types, water plays a large role in providing nutrients or contributing to toxic- ity and adverse health effects. The quality, nutrient content, and availability of water differ throughout the world; variation depends on many things, including climate, location, and the eco- nomic status of the country. Water

characteristics can dramatically shift in unstructured situations such as war.

Located in the dry climate of the Middle East, Iraq continually suffers from water scarcity, and a multitude of factors contribute to water pollution. In the past cen- tury, the population of Iraq has experienced countless wars, di- rectly and indirectly exacerbating long-standing waterborne disease issues. Throughout the country, outbreaks of cholera, typhoid fever, malaria, and many other diseases followed every war. Alarming numbers of waterborne disease outbreaks continue to be recorded throughout Iraq. Com- bined governmental reform and public health efforts are urgently needed to implement and main- tain long-lasting change.

Significant, long-lasting reduc- tion in waterborne disease will require public health and health care reform; improvements in ac- cess to potable water, such as remineralizing desalinated water; monitoring and evaluation sys- tems; and educational interven- tions. Long-term commitment to change in Iraq could provide in- dividual access to clean water, alleviate interrelated cycles of health disparities, and promote health and well-being throughout the country. j

About the Author Tara Rava Zolnikov is with the Department of Environmental Health, Harvard School of Public Health, Boston, MA. Correspondence should be sent to Tara

Rava Zolnikov, Environmental Health, 665 HuntingtonAve, Boston,MA02115 (e-mail: tarazolnikov@gmail.com). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

This article was accepted October 13, 2012.

Acknowledgments I thank the Qatar Foundation for spon- soring the Middle East Environmental Urbanization Project.

Special thanks to the editors and the anonymous reviewer for their comments and critical insight.

Note. The views expressed within the article are my responsibility alone.

Human Participant Protection No protocol approval was required be- cause no human participants were in- volved.

References 1. Metz HC. Iraq: A Country Study. Washington, DC: Federal Research Di- vision, Library of Congress; 1990.

2. US Department of State. Iraq. Avail- able at: http://www.state.gov/r/pa/ei/ bgn/6804.htm. Accessed February 20, 2012.

3. Litz B. The Unique Circumstances and Mental Health Impact of the Wars in Afghanistan and Iraq. Washington, DC: National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs; 2007.

4. Chen L, Evans T, Apand S, et al. Human resources for health: overcoming the crisis. Lancet. 2004;364(9449): 1984—1990.

5. Acheson ED. Health problems in Iraq. BMJ. 1992;304(6825):455—456.

6. United Nations Educational Scien- tific and Cultural Organization, Office for Iraq. Iraq’s water in the international press. 2011. Available at: http://www. unesco.org/new/en/iraq-office/natural- sciences/water-sciences/water-in-iraq. Accessed April 1, 2012.

7. Kleiner SM. Water: an essential but overlooked nutrient. J Am Diet Assoc. 1999;99(2):200—206.

8. United States Geological Survey. Water properties: facts and figures about water. 2012. Available at: http://ga. water.usgs.gov/edu/waterproperties. html. Accessed February 4, 2012.

9. Nutrients in Drinking Water. Geneva, Switzerland: World Health Organization; 2005.

10. Institute of Medicine. Dietary refer- ence intakes: water, Potassium, Sodium, Chloride, and Sulfate. 2004. Available at: http://www.iom.edu/Reports/2004/ Dietary-Reference-Intakes-Water- Potassium-Sodium-Chloride-and-Sulfate. aspx. Accessed March 20, 2012.

11. Committee to Review Dietary Ref- erence Intakes for Vitamin D and Cal- cium, Institute of Medicine. Dietary Ref- erence Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 2012.

12. Dawson-Hughes B, Harris SS, Palermo NJ, Castaneda-Sceppa C, Rasmussen HM, Dallal GE. Treatment

CRISES AND OPPORTUNITIES

e6 | Crises and Opportunities | Peer Reviewed | Zolnikov American Journal of Public Health | Published online ahead of print April 18, 2013

with potassium bicarbonate lowers cal- cium excretion and bone resorption in older men and women. J Clin Endocrinol Metab. 2009;94(1):96—102.

13. Rude RK. Magnesium deficiency: a cause of heterogeneous disease in humans. J Bone Miner Res. 1998;13(4): 749—758.

14. Saris NE, Mervaala E, Karppanen H, Khawaja JA, Lewenstam A. Magnesium. An update on physiological, clinical, and analytical aspects. Clin Chim Acta. 2000; 294(1—2):1—26.

15. Board on the Health of Select Pop- ulations, Institute of Medicine. Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan. Washington, DC: National Academies Press; 2011.

16. Shils ME. Magnesium in Modern Nutrition in Health and Disease. 9th ed. New York, NY: Lippincott Williams and Wilkins; 1999.

17. Elisaf M, Milionis H, Siamopoulos KC. Hypomagnesemic hypokalemia and hypocalcemia: clinical and laboratory characteristics. Miner Electrolyte Metab. 1997;23(2):105—112.

18. Encyclopedia Britannica. Fluoride deficiency. 2012. Available at: http:// www.britannica.com/EBchecked/topic/ 211435/fluoride-deficiency. Accessed April 1, 2012.

19. ten Cate JM. Fluorides in caries prevention and control: empiricism or science. Caries Res. 2004;38(3):254— 257.

20. World Health Organization. De- pleted uranium—fact sheet. 2003. Avail- able at: http://www.who.int/mediacentre/ factsheets/fs257/en/print.html. Accessed April 1, 2012.

21. World Health Organization. Petro- leum products in drinking water. 2003. Available at: http://www.who.int/ water_sanitation_health/dwq/chemicals/ Petroleum%20Productsrev071105.pdf. Accessed March 20, 2012.

22. Chandra RK. Nutrition and the im- mune system: an introduction. Am J Clin Nutr. 1997;66(2):460S—463S.

23. WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanita- tion. Progress on Drinking Water and San- itation: 2012 Update. Geneva, Switzerland: World Health Organization; 2012.

24. Suleymanova M. Access to water in developing countries. Available at: http:// www.parliament.uk/documents/post/ pn178.pdf. Accessed February 10, 2012.

25. World Health Report 2002. Reducing Risks, Promoting Healthy Life. Geneva, Switzerland: World Health Organization; 2002.

26. Weiss RA, McMichael AJ. Social and environmental risk factors in the emergence

of infectious disease. Nat Med. 2004;10 (12 suppl):S70—S76.

27. Simmons JS, Whayne TF, Anderson GW, Horack HM. Iraq. In: Global Epide- miology: A Geography of Disease and Sanitation. Vol 3. The Near and Middle East. Philadelphia, PA: JB Lippincott Company; 1954:21—49.

28. Central Intelligence Agency. Fact sheet: Iraq. 2012. Available at: https:// www.cia.gov/library/publications/the- world-factbook/geos/iz.html. Accessed April 9, 2012.

29. Oldfield EC 3rd, Wallace MR, Hyams KC, Yousif AA, Lewis DE, Bourgeois AL. Endemic infectious dis- eases of the Middle East. Rev Infect Dis. 1991;13(suppl 3):S199—S217.

30. Shamo FJ. Malaria in Iraq. 1999. Available at: http://www.emro.who.int/ rbm/malariasituation1999.pdf. Accessed March 26, 2012.

31. World Health Organization. Iraq integrated control of communicable dis- eases. 2007. Available at: http://www. emro.who.int/iraq/pdf/Communicable Diseases_06_07.pdf. Accessed March 14, 2012.

32. World Health Organization. Health system profile: Iraq. 2006. Available at: http://gis.emro.who.int/HealthSystem Observatory/PDF/Iraq/Full%20Profile. pdf. Accessed September 18, 2012.

33. World Health Organization. Poten- tial impact of conflict on health in Iraq. 2003. Available at: http://www.who.int/ features/2003/iraq/briefings/iraq_ briefing_note/en/index3.html. Accessed September 18, 2012.

34. World Health Organization. Cholera country profile: Iraq. 2010. Available at: http://www.who.int/cholera/countries/ IraqCountryProfile2010.pdf. Accessed September 18, 2012.

35. Awqati NA, Ali MM, Al-Ward NJ, et al. Causes and differentials of childhood mortality in Iraq. BMC Pediatr. 2009;9:40.

36. US Agency for International Devel- opment. The bottled water market in Iraq. 2007. Available at: http://www.iajd.org/ files/3_1.pdf. Accessed March 15, 2012.

37. World Health Organization. Stories that count: regional office for eastern Mediterranean Iraq representative office. 2009. Available at: http://www.emro. who.int/iraq/pdf/progress_report_2009. pdf. Accessed March 15, 2012.

38. Al-Janabi KWS, Alazawi FN, Mohammed MI, Kadhum AAH, Mohamad AB. Chlorophenols in Tigris River and drinking water of Baghdad, Iraq. Bull Environ Contam Toxicol. 2011;87(2):106—112.

39. Douabul AAZ, Al-Saad HT. Seasonal variations of oil residues in water of Shatt al-Arab river,Iraq. Water Air Soil Pollut. 1985;24(3):237—246.

40. Lando B. Iraq oil report. 2011. Available at: http://www.iraqoilreport. com/oil/production-exports/oil-pipeline- leak-threatening-basra-water-supply- 6465. Accessed March 20, 2012.

41. Dyer O. Infectious diseases increase in Iraq as public health service deterio- rates. BMJ. 2004;329(7472):940.

42. UNICEF. Environmental survey in Iraq (water sanitation and municipal ser- vices). 2011. Available at: http://www.iau iraq.org/documents/1555/Environmental %20Survey%20%20ENGLISH.pdf. Ac- cessed April 9, 2012.

43. Federal Research Division, Library of Congress. Country profile: Iraq. 2006. Available at: http://lcweb2.loc.gov/frd/ cs/profiles/Iraq.pdf. Accessed April 9, 2012.

44. Inter-Agency Information and Analysis Unit. Water in Iraq fact sheet. 2011. Available at: http://www.iauiraq. org/documents/1319/Water%20Fact% 20Sheet%20March%202011.pdf Ac- cessed April 9, 2012.

45. Uauy R. The impact of the Brazil experience in Latin America. Lancet. 2011;377(9782):1984—1986.

46. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet. 2011;377(11):1778—1797.

47. Utzinger J, Wyss K, Moto DD, Tanner M, Singer BH. Community health outreach program of the Chad-Cameroon petroleum development and pipeline project. Clin Occup Environ Med. 2004;4 (1):9—26.

48. Morton MJ, Burnham GM. Dilemmas and controversies within civilian and military organization in the execution of humanitarian aid in Iraq: a review. Am J Disaster Med. 2010;5(6):385—391.

49. US Army. Iraq, U.S. partner to re- furbish water treatment plants. 2009. Available at: http://www.army.mil/ article/27055. Accessed April 9, 2012.

50. Veterans for Peace. Iraq water pro- ject. 2011. Available at: http://www. veteransforpeace.org/our-work/healing- the-wounds-of-war/iraq-water-project. Accessed April 9, 2012.

51. Mintz ED, Reiff FR, Tauxe FV. Safe water treatment and storage in the home. A practical new strategy to prevent wa- terborne diseases. JAMA. 1995;273(12): 948—953.

52. Swerdlow DL, Malanga G, Begokyian G. Epidemic of antimicrobial resistant Vibrio cholerae O1 infections in a refugee camp, Malawi. In: Program and Abstracts of

the 31st Interscience Conference on Anti- microbial Agents and Chemotherapy. Washington, DC: American Society for Microbiology; 1991. Abstract 529.

53. Al-Riahi M, Al-Kayssi A. Some com- ments on time variation in solar radiation over Baghdad, Iraq. Renewable Energy. 1998;14(1—4):479—484.

54. Koehler JE, Ries A, Tauxe R. Cholera risk assessment in Texas ‘Colonias,’ El Paso County, 1991 [abstract]. In: Pro- gram and Abstracts of the 42nd Annual Epidemic Intelligence Service Confer- ence; April 19—23, 1993; Atlanta, GA.

55. United Nations Water. Status report on integrated water resources manage- ment and water efficiency plans. 2008. Available at: http://www.unwater.org/ downloads/UNW_Status_Report_IWRM. pdf. Accessed April 1, 2012.

56. McLaughlin M. Implementation as mutual adaptation: change in classroom organization. In: Williams W, Elomore R, eds. Social Program Evaluation. San Diego, CA: Academic Press; 1976.

57. Welsh WN, Harris PW. Criminal Justice Policy and Planning. Cincinnati, OH: Anderson; 1999.

58. Nimmer RT. The Nature of System Change: Reform Impact in the Criminal Courts. Chicago, IL: American Bar Foun- dation; 1978.

59. National Child Health Survey. Bagh- dad, Iraq: Ministry of Health; 1990.

60. Drèze J, Gazdar H. Hunger and Poverty in Iraq. World Dev. 1992;20(7): 921—945.

61. Center for Economic and Social Rights. The human costs of war in Iraq. 2003. Available at: http://www.cesr.org/ downloads/Human%20Costs%20of% 20War%20in%20Iraq.pdf. Accessed April 1, 2012.

62. United Nations World Food Pro- gramme. Comprehensive food security and vulnerability analysis in Iraq. 2008. Available at: http://www.krso.net/files/ articles/220611063309.pdf. Accessed April 1, 2012.

63. Collins English Dictionary. Desalina- tion. 2012. Available at: http://dictionary. reference.com/browse/desalination. Ac- cessed February 20, 2012.

64. MENAFN. Aswat al-Iraq [Voices of Iraq]. Iraq—PM opens 8 water desalina- tion stations in Basra. 2010. Available at: http://www.menafn.com/menafn/qn_news_ story_s.aspx?storyid=1093306905. Accessed April 10, 2012.

CRISES AND OPPORTUNITIES

Published online ahead of print April 18, 2013 | American Journal of Public Health Zolnikov | Peer Reviewed | Crises and Opportunities | e7