Acute malnutrition among young children in Iraq has nearly doubled since the United States led an invasion of the country 20 months ago, according to surveys by the United Nations, aid agencies and the interim Iraqi government.
After the rate of acute malnutrition among children younger than 5 steadily declined to 4 percent two years ago, it shot up to 7.7 percent this year, according to a study conducted by Iraq's Health Ministry in cooperation with Norway's Institute for Applied International Studies and the U.N. Development Program. The new figure translates to roughly 400,000 Iraqi children suffering from "wasting," a condition characterized by chronic diarrhea and dangerous deficiencies of protein.
"These figures clearly indicate the downward trend," said Alexander Malyavin, a child health specialist with the UNICEF mission to Iraq.
The surveys suggest the silent human cost being paid across a country convulsed by instability and mismanagement. While attacks by insurgents have grown more violent and more frequent, deteriorating basic services take lives that many Iraqis said they had expected to improve under American stewardship.
Iraq's child malnutrition rate now roughly equals that of Burundi, a central African nation torn by more than a decade of war. It is far higher than rates in Uganda and Haiti.
"The people are astonished," said Khalil M. Mehdi, who directs the Nutrition Research Institute at the Health Ministry. The institute has been involved with nutrition surveys for more than a decade; the latest one was conducted in April and May but has not been publicly released.
Mehdi and other analysts attributed the increase in malnutrition to dirty water and to unreliable supplies of the electricity needed to make it safe by boiling. In poorer areas, where people rely on kerosene to fuel their stoves, high prices and an economy crippled by unemployment aggravate poor health.
"Things have been worse for me since the war," said Kasim Said, a day laborer who was at Baghdad's main children's hospital to visit his ailing year-old son, Abdullah. The child, lying on a pillow with a Winnie the Pooh washcloth to keep the flies off his head, weighs just 11 pounds.
"During the previous regime, I used to work on the government projects. Now there are no projects," his father said.
When he finds work, he added, he can bring home $10 to $14 a day. If his wife is fortunate enough to find a can of Isomil, the nutritional supplement that doctors recommend, she pays $7 for it.
"But the lady in the next bed said she just paid $10," said Suad Ahmed, who sat cross-legged on a bed in the same ward, trying to console her skeletal 4-month-old granddaughter, Hiba, who suffers from chronic diarrhea.
Iraqi health officials like to surprise visitors by pointing out that the nutrition issue facing young Iraqis a generation ago was obesity. Malnutrition, they say, appeared in the early 1990s with U.N. trade sanctions championed by Washington to punish the government led by President Saddam Hussein for invading Kuwait in 1990.
International aid efforts and the U.N. oil-for-food program helped reduce the ruinous impact of sanctions, and the rate of acute malnutrition among the youngest Iraqis gradually dropped from a peak of 11 percent in 1996 to 4 percent in 2002. But the invasion in March 2003 and the widespread looting in its aftermath severely damaged the basic structures of governance in Iraq, and persistent violence across the country slowed the pace of reconstruction almost to a halt.
In its most recent assessment of five sectors of Iraq's reconstruction, the Center for Strategic and International Studies, a Washington research group, said health care was worsening at the quickest pace.
"Believe me, we thought a magic thing would happen" with the fall of Hussein and the start of the U.S.-led occupation, said an administrator at Baghdad's Central Teaching Hospital for Pediatrics. "So we're surprised that nothing has been done. And people talk now about how the days of Saddam were very nice," the official said.
The administrator, who would not give his full name for publication, cited security concerns faced by Iraqi doctors, who are widely perceived as rich and well-connected and thus easy targets for thieves, extortionists and the merely envious or vengeful. So many have been assassinated, he said, that the Health Ministry recently mailed out offers to expedite weapon permits for doctors.
Violence has also driven away international aid agencies that brought expertise to Iraq following the U.S. invasion.
Since a truck bombing at the U.N. headquarters in Baghdad killed more than 20 people last year, U.N. programs for Iraq have operated from neighboring Jordan. Doctors Without Borders, a group known for its high tolerance for risk and one of several that helped revive Iraq's Health Ministry in the weeks after the invasion, evacuated this fall.
CARE International closed down in October after the director of its large Iraq operation, Margaret Hassan, was kidnapped. She is now presumed to be dead. The huge Atlanta-based charity had remained active in Iraq through three wars, providing hospitals with supplies and sponsoring scores of projects to offer Iraqis clean drinking water.
By one count, 60 percent of rural residents and 20 percent of urban dwellers have access only to contaminated water. The country's sewer systems are in disarray.
"Even myself, I suffer from the quality of water," said Zina Yahya, 22, a nurse in a Baghdad maternity hospital. "If you put it in a glass, you can see it's turbid. I've heard of typhoid cases."
The nutrition surveys indicated that conditions are worst in Iraq's largely poor, overwhelmingly Shiite Muslim south, an area alternately subject to neglect and persecution during Hussein's rule. But doctors say malnutrition occurs wherever water is dirty, parents are poor and mothers have not been taught how to avoid disease.
"I don't eat well," said Yusra Jabbar, 20, clutching her swollen abdomen in a fly-specked ward of Baghdad's maternity hospital. Her mother said the water in their part of Sadr City, a Shiite slum on the capital's east side, is often contaminated. Her brother contracted jaundice.
"They tell me I have anemia," Jabbar said. Doctors said almost all the pregnant women in the hospital do.
"This is not surprising because since the war, there is lots of unemployment," Yahya said. "And without work, they don't have the money to obtain proper food.''
Iraqis say such conditions carry political implications. Baghdad residents often point out to reporters that after the 1991 Persian Gulf War left much of the capital a shambles, Hussein's government restored electricity and kerosene supplies in two months.
"Yes, there is a price for every war," said the official at the teaching hospital. "Yes, there are victims. But after that?
"Oh God, help us build Iraq again. For our children, not for us. For our kids," the official said.