BMJ 2003;326:779 ( 12 April )

Baghdad's hospitals struggle to cope with war wounded

Owen Dyer, London As the BMJ went to press on Tuesday, reports from Baghdad's hospitals suggested that they were no longer able to cope with the flow of people wounded in the war. An American armoured foray into the city centre on 6 April brought the heaviest casualties to date in Baghdad, and the Yarmouk Hospitalone of five in the city able to treat war woundedwas receiving 100 new casualties an hour, according to the International Committee of the Red Cross.

Despite the power cut that has affected much of the city since 3 April, the hospitals had electric power from backup generators. They were often plunged into darkness, however, when the generators were shut down to prevent overheating.

Problems were most severe in the south of the city, the Red Cross said, because a damaged bridge and continued fighting were preventing the wounded from reaching the city centre, where the main hospitals are located.

Many hospital staff could not reach work, with the result that doctors were performing nurses' duties and even pushing trolleys. Medical supplies were holding up in Baghdad, but in some hospitals the supply of fresh water laid up before the war was almost exhausted.

Another 30000 one litre bags were due to be distributed, said the Red Cross. Clean water, rather than food or medicine, was cited as the most acute need in southern and central Iraq. Even Umm Qasr, the port city that was declared under British-American control in the first days of the war, was still not being properly provisioned with water more than two weeks later, according to aid workers from the Catholic Agency for Overseas Aid (Cafod).

"We expected that a town of 40000 people under coalition control for the best part of two weeks would have a humanitarian impact, but it was horrendous," said the Cafod workers, speaking to journalists in Kuwait after visiting the port. "If they can't organise aid for 40000 people in Umm Qasr we are worried about them doing it for one million-plus in Basra and 22 million in Iraq."

Umm Qasr is the entry point for all aid ships. Early in the war, the Royal Fleet Auxilliary Sir Galahad was able to dock there, but although the British government described the Sir Galahad as an aid ship, it later emerged that most of its cargo was munitions and supplies for the troops. Other ships, including two Australian vessels laden with 100000 tonnes of wheat, were still unable to dock when the BMJ went to press, a result of fears of mines in the channel.

Last weekend, the British army completed a pipeline from Kuwait to Umm Qasr that is said to carry two million litres of water a day. But the Cafod workers said truck drivers hired to carry water from the pipeline to isolated areas were selling it for profit. The army said it was investigating this claim.

Care International said that 60% of Iraq's water treatment plants and all of Iraq's sewage plants were out of action, with the result that 500000 tonnes of raw sewage were being pumped into the country's rivers and lakes every day.

The Red Cross had brought some aid to the southern city of Basra by the time the BMJ went to press, crossing the front lines with two trucks on 4 April. They helped to restore water supplies in part of the city.

Aid agencies said the access given to the Red Cross showed why neutral civilian workers were essential. The agencies are united in refusing to work with the military or to accept funding from the allies, fearing that they will become pawns in the struggle for "hearts and minds."

A declaration by the directors of Oxfam, Save the Children, Christian Aid, ActionAid, and Cafod said: "It is impossible for armed forces fighting a war to provide impartial humanitarian assistance on the basis of need. By definition, the priorities of combatant forces are military and adversarial, not humanitarian."

The dangers of humanitarian work were again highlighted when two workers with MÚdecins Sans FrontiÓres were reported missing on 2 April. They had been providing medical support at the Al-Kindi Hospital in northern Baghdad. Four other members of the agency are safe and accounted for. The group has suspended its Iraq operations.

According to the World Health Organization, four medical facilities have been destroyed or damaged in the conflict. Like the private agencies, the United Nations is gearing up for what looks set to be the biggest aid operation in history, launching a record appeal for $2.2bn (ú1.4bn; a2.1bn) to fund aid for Iraq. The UN last week also restarted the oil for food programme, suspended when the war began. Before the war, 60% of Iraq's population was dependent on food supplied by the UN. A separate UN agency, the World Food Programme, began deliveries of grain to northern Iraq last weekend.

The International Health Advocacy Group at University College London said that the United States was spending 120 times more on its military campaign than it had committed to humanitarian aid for Iraq.

Writing in the Journal of Epidemiology and Community Health, the group also quoted research by the physicians' antiwar group Medact which predicted that between 48000 and 260000 people will die in the war and the three subsequent months. No one has ventured to guess actual civilian losses to date (http://jech. (See p 780.)